Tuesday, February 3, 2015

The NHS financial crisis: E-QIPP-ing the nursing workforce with the skills to drive quality and efficiency improvements

It seems that not a week goes by without some form of media headline trumpeting the scale of the financial crisis confronting the NHS. NHS finances is a major issue requiring urgent and sustainable solutions. In the past few years, the National Audit Office repeatedly questioned the sustainability of savings made to date. The easiest savings have been made – through a pay freeze for public sector staff, reductions in the prices paid for healthcare, and cutting back-office costs. Yet these savings have yet to be driven by fundamental service transformations at scale. The latest report by the Public Accounts Committee underlines the depth of the problem, pointing out that the proportion of NHS trusts and foundation trusts in deficit increased from 10% in 2012-13 to 26% in 2013-14. According to the regulator Monitor, the problems are particularly bad for hospitals, with 80% of acute foundation trusts reporting a deficit half way through the current financial year.

More worryingly, there is evidence that ‘cuts’ may be conflated with ‘savings’. This reflects the lack of a whole system approach in looking at how we make decisions about resource allocation. After all, the Mid Staffordshire NHS Foundation Trust Public Inquiry has shown how the Trust Board’s focus on short term cost control contributed to a range of adverse impacts on the quality and safety of care, that have longer term financial (and other) implications.

In relation to nursing, a study published in the British Medical Journal indicated that reducing cost through shedding or not replacing frontline nursing staff impacts on the quality and safety of care that, in turn, have implications not only on patient outcomes but also on the financial costs to the health and social care system.

Putting NHS finances on a sustainable footing requires not only different ways of doing things, but also new skills. While it has been estimated that innovations designed and implemented by clinicians could have a value of £9 billion per year in the UK, to date little has been done to harness this potential. As the largest professional group within the NHS, nurses play a critical role in delivering services and innovations in a way that achieves clinical outcomes and patient satisfaction, and will be vital in helping the NHS meet its quality and efficiency challenge. However, nurses often lack the skills to formulate and put forward arguments about the economic impact of what they do, over and above the clinical outcomes they contribute toward achieving. Nurses and other healthcare professionals often feel like they are reacting to, rather than driving efficiency initiatives.

OPM developed a programme aimed at building the capability of nurses and other members of the public service workforce to be able to generate evidence of the costs and benefits of various services in order to inform ongoing service improvements. Since 2013, OPM has been delivering this programme to cohorts of nurses in partnership with the Royal College of Nursing (RCN), with generous funding from the Burdett Trust for Nursing. Evidence to date shows how trained nurses contribute proactively to the Quality, Innovation, Productivity and Prevention (QIPP) agenda – in many cases helping to generate ‘cashable’ savings.

For example, a nurse in Scotland produced an economic assessment that showed how her heart failure nurse liaison service helped reduce both hospital admission rates and lengths of stay per admission, while also reducing demands on other professionals’ time. She was able to calculate efficiencies of around £454,928 per year, representing a return on investment of £489 per patient. More importantly, based on the evidence, she was able to make recommendations for where there may be further scope for increasing efficiencies. She identified that by improving part of the patient referral pathway, the service is likely to generate additional efficiencies, the potential return on investment rising to between £671 and £779 per patient per year. Based on this evidence, she was able to mobilise other colleagues and senior management to effect service re-design in a way that secures both quality and efficiency. This is testament to how an empowered workforce, with the right skills, can help the NHS meet its financial challenge while maintaining a clear focus on high quality care.

The Public Accounts Committee noted that radical service reconfigurations require “significant upfront investment”, and that this will become increasingly difficult with less money available for such investment as more NHS organisations move into deficit. Equally, a case may be made that securing a sustainable financial future for the NHS requires not only investment in services and service transformations; but also investments in the workforce to be able to drive meaningful change ‘on the ground’. Valuing public services means valuing our public service workforce, and seeing them as part of the solution.


Download a copy of ‘A guide to economic assessment in nursing’ by clicking on the icon below:
Front page from Economic-Assessment-2015

Note: The programme is currently being delivered to cohorts of nurses in England, and there are still a few places available. More information about the programme, and the process for registering an expression of interest to participate, is available from the RCN website. ‘A guide to economic assessment in assessment in nursing’  supports the provision of RCN and OPM training in how to perform economic assessments and use economic evidence to demonstrate the value of nurse-led innovation.

Friday, January 30, 2015

Towards a hate crime care pathway: lessons from Leicestershire

It is Hate Crime Awareness Week, and I would like to take the opportunity to assert the importance of reframing hate crime beyond its narrow criminal justice focus. In a blog for the International Network for Hate Studies last year, I argued that health and social care agencies can play three critical roles in relation to hate crime: (1) to provide treatment and support to hate crime victims; (2) to help prevent hate crimes by identifying and acting on the early indicators of repeat victimization; and (3) as potential offenders, particularly in institutional care settings, where professionals may perpetrate acts commonly termed ‘abuse’ against inpatients.

In the latter half of 2014, I started working with Leicestershire Partnership NHS Trust and its partners on developing a hate crime care pathway. We hope to share learning in order to inspire and encourage others to develop joined up approaches to tackle hate crime and support hate crime victims.

Making it real for health and social care

As a first step, we need to understand the context in which health and social care professionals are working within. For example:

The implications of all the above are then drawn out for health and social care professionals and agencies so that the issues are ‘made real’ for them. For example:

A conceptual framework

Building on the above, we developed a conceptual framework for informing potential solutions. This involved clustering services into ‘acute’, ‘primary’, ‘community’ and ‘specialised’. Within each of these headings, we worked with partners to identify the types of services that played a supportive and/or prevention function, as well as whether service users are likely to present with physical and/or mental health conditions.

As a result of this, we came to the following recommendations:

Friday, January 23, 2015

Pharmacies: a healthy dose of listening to users

It’s a busy time for pharmacies. Many of us are turning to pharmacies for something to fight off seasonal sniffles, or to help with New Year’s resolutions, like losing weight or quitting smoking.

But it’s also an interesting time for the community pharmacy landscape in general, with debates currently underway about the future role of pharmacies and how they link to other health services.

The NHS Five Year Forward View called for the greater involvement of pharmacies in healthcare, including as part of new models of primary care. Pharmacy organisations have also been urging parties to sign up to their 2015 manifesto for a greater role for pharmacies, ahead of the general election.

Locally, many pharmacies are already offering services beyond just selling medicines and dispensing prescriptions – for example treating minor ailments, flu vaccinations, providing advice and support for healthy lifestyles, or advising users on how to best use new medicines.

However, in order to make sure new roles and services for pharmacies work on the ground and are taken up by the public, it’s also important to understand the needs, behaviours and attitudes of people using pharmacies.

Pharmaceutical Needs Assessments (PNAs) look into existing pharmacy provision in a local authority area, to assess how these are meeting the needs of the local population. All Health and Wellbeing Boards need to publish their local PNAs by March 31st 2015 and many local authorities have been putting out their draft PNAs to the local public for consultation.

Some local authorities have shown a strong commitment to understanding the experiences of pharmacy users in their areas, using innovative methods to directly engage them in the PNA consultation process. OPM were involved in this in the London boroughs of Camden and Islington, running focus groups with specific types of pharmacy users to inform these two boroughs’ PNAs, which recently went out to consultation (Islington here and Camden here).

Our approach enabled us to start with actual experiences and attitudes, hearing from local residents about what worked well, and not so well, in their local pharmacies. It also helped uncover the views of those with particular needs – such as long-term conditions, and mental health needs, who tend to rely heavily on their local pharmacy.

This helped to put the voices of pharmacy users back into the debate, with comments such as:

“It’s nice to be able to walk in and speak to someone.”

“I never have any fears about going to the chemist. They are nearly always polite and attentive, and the pharmacist is very helpful”

“I don’t really know comprehensively what they actually provide.”

In the focus groups, we heard that pharmacies in the two boroughs are generally well respected and trusted, but users also voiced some important pragmatic concerns about locations and opening hours, accessibility, and how particular services work. Some points raised closely match those also identified at the national level: some people were already happily using new pharmacy services, but awareness of the full range of services available was generally patchy. And many of these findings were also echoed in similar work OPM undertook last year directly engaging harder to reach groups about their pharmacy use for NHS England’s Call to Action on Pharmacies.

This kind of research underlines the importance of listening to users’ experiences, particularly disadvantaged ones or those with higher needs, when commissioning or reshaping pharmacy services.

PNAs needing to be fully revised every three years, and with more long-term changes to the pharmacy landscape afoot, it’s more important than ever that pharmacy users are heard and involved along the way. This is essential to ensure that any changes to pharmacy services will actually benefit all local users.

Wednesday, January 21, 2015

Safety Measurement and Monitoring Programme

The Health Foundation has appointed OPM in partnership with wdid (Ward Downham Improvement Design) to work with them on the new Safety Measurement and Monitoring Programme. We will support the Health Foundation with the overall project management, learning capture and sharing, and the development of resources to support the potential next phase of the programme.

The programme will support those working in the NHS to test and develop a new way of measuring and monitoring safety. This is based on Professor Charles Vincent and colleagues’ measurement and monitoring framework, published by the Health Foundation in 2013. It aims to translate the research into an approach that can be successfully applied in diverse healthcare settings.

We will be working with three regional improvement organisations – Advancing Quality Alliance (AQuA), Healthcare Improvement Scotland and Yorkshire and Humber Improvement Academy – who will each work with two frontline NHS organisations to test and develop this new framework over an 18 month period.

In partnership with the Health Foundation, OPM and wdid will work closely with the regional improvement organisations and frontline organisations to identify and create resources that can support others in the NHS to use the new approach to measuring and monitoring safety described by the framework.

The six frontline participant organisations are:

Each site will test the framework across a different service area. For example, Bradford District Care Trust will be looking at the interface and transitions between services for people with mental health problems. NHS Borders will be applying the framework to their care pathway for older people. The North West Ambulance Service NHS Trust will be developing safety measures to guide the care paramedics give to patients.

Friday, December 12, 2014

Making It Better: Manchester’s reconfiguration of maternity, neonatal and paediatric services holds essential lessons about how to lead successful change

2014 has been another year of attempts to future proof the NHS. Policy proposals within The ‘NHS Five Year Forward Review’ were welcomed by many, and the recently released Dalton Review on the future of hospitals further challenges NHS leaders to think differently about how healthcare services are organised and delivered. Throughout the past year, CCGs too have devoted considerable time to producing two-year and five-year strategic plans for their local areas.

The ultimate goal of all this future thinking is to create financially viable and sustainable local health systems, but this is more easily imagined than achieved. For if there’s one thing the NHS is good at, it’s planning. Implementing complex change is where things get messy and stalled. Few places have managed to transform local health services without hiccoughs and major setbacks.

Particularly after the election,  2015 should be an watershed year for the NHS – especially for its commissioners. What should CCG leaders be doing now to ensure their plans are achievable? Learning from what others did well – and also from their mistakes – would be a good place to start.

OPM recently completed an evaluation study of Greater Manchester’s ‘Making it Better’ reconfiguration of maternity, neonatal and paediatric services.  Through this evaluation, we have identified some important lessons for CCG leaders and their local partners.

The first observation is that transformational change takes time – and patience. The Making it Better process actually took about 12 years from conception to final delivery.  While there were many setbacks along the way, the programme managed to move from planning to public consultation to implementation by 2007. The reconfiguration of hospital services was completed over five years in 2012.

A tremendous number of people were involved in the delivery of the changes.  Local implementation groups were formed, with task-based delivery groups and clinical advisory groups leading most of the work and taking on clinical accountability.

Governance mattered, too; a programme board was set up, and there were regular meetings between providers and project leaders. The project’s governance structures and processes ensured that clinicians, executive directors and managers across the whole of Greater Manchester presented a united front and worked well together. Governance was crucial to maintaining focus and momentum over such a long period of time.

But what mattered most of all was the clinical credibility of the reconfiguration – both in terms of visible and continuous clinical leadership and the clinical merits of the proposed changes.

There was genuine clinical ownership of the need for change across the whole of Greater Manchester and impartial clinical and managerial leadership for paediatrics, obstetrics and neonatology. This promoted a strong recognition that the need for change was underpinned by a robust clinical argument rather than one of efficiency.

With the continuity of clinical leadership, great effort was put into ongoing engagement of clinicians during the implementation process. Strong clinical participation ensured that care options were underpinned by robust data analysis and supported more widely. A networked approach proved vital; the networks acted as clinical reference groups, and helped to build consensus amongst local stakeholders, such as frontline staff in the respective NHS Trusts.

One of our most interesting evaluation findings concerned leadership capacity building.  Making it better offered many clinicians, senior executives and managers the opportunity to develop new skills and experiences. Being responsible for the safe implementation of the reconfiguration led to personal satisfaction and a strong ethos of commitment to change.

Leaders became adept at managing vested interests. Making it better involved the relocation of inpatient care from some Trusts. Where this occurred clinicians had to balance their personal views with the need for safe and sustainable services across all of Greater Manchester.

Making it better spanned twelve years and took place within a context of great change across the NHS. The disbandment of PCTs and introduction of CCGs led to a lack of continuity on commissioning boards at a critical time in the reconfiguration, as well as turnover of managerial staff, and the concomitant loss of organisational memory.

This situation reinforced our conclusion that the key ingredient for success was the continuity, strength and commitment of the Making it Better clinical leadership team.

Such a dynamic environment will undoubtedly exist for CCGs taking forward their newly agreed strategic plans. Maintaining the momentum locally will require long-term commitments of GPs and their consultant partners. The question is: Will local leaders have the stamina, drive, resources and skills to make a difference to their own local health services?

Part 2: How to resource reconfiguration delivery programmes (to follow)

Download the Making it Better interactive PDF

Download the Making it Better full report



Friday, December 12, 2014

Evaluation of Making it Better

Evaluating the programme to reconfigure maternity, neonatal and children’s services in Greater Manchester

In 2013, the former North-West Strategy Health Authority commissioned an evaluation of the ‘Making it Better’ reconfiguration programme that took place in Greater Manchester between 2000 and 2012. The purpose of this evaluation was to review good practice and lessons learnt from the management and delivery of the change programme, that could be of interest to other health economies planning service changes in future. It was not intended to evaluate the specific quality, outcomes and productivity benefits of the service changes themselves.

This report presents the many and varied lessons emerging from the Making it Better reconfiguration, which will be of interest to stakeholders across the health and care sector. The evaluation has involved a retrospective review of the processes involved in Making it Better, with the aim of generating transferable learning for others considering or currently undertaking major service change.

Thursday, October 9, 2014

KIDS launches free information to support everyone affected by the new Special Educational Needs and Disability (SEND) reforms

Leading disabled children’s charity KIDS has just launched a new suite of resources to support families and carers of disabled children, commissioners and providers, to help them navigate the reforms to Special Educational Needs and Disability provision.

As part of the ‘Making it Personal:2’ project, sponsored by the Department for Education, OPM worked with KIDS to develop these resources, which explore how personal budgets and the local offer will benefit families. The suite aims to reach a range of audiences to help them understand how they can use the new system to their advantage and provide a holistic service to families and carers.

It includes:

Children and Families Minister Edward Timpson said:

“I’m proud we’ve sponsored these fantastic resources which will complement our SEND reforms. Children, young people and their families will now be at the centre of a more simple, joined-up system that provides the support they deserve. We’re committed to helping families get the best information possible about the new system that will help children and young people with SEND from birth to 25.”

Regional events to support this will be taking place from October 2014 to March 2015.

If you have any questions about this project, or would like to discuss it further, please don’t hesitate to get in touch with Claire Lazarus at clazarus@opmassociates.co.uk or call 0845 055 3900.



Thursday, September 25, 2014

25th anniversary guest blog series: The challenges and opportunities facing public services

Public services are undeniably facing a period of intense, unrelenting challenge. This is the reality felt by the front line and those who use services every day. The challenges are significant, but they are not without hope and opportunity, where there is political will to make things work.

The challenges are not simple, and they are not isolated. In many ways, we are now dealing with the consequences of success – more than 13,000 people celebrated their 100th birthdays in 2013 – a rise of more than 70 per cent in just a decade. Those individual people have done well to reach the milestone, but individuals do not do this alone – they did it with a century’s worth of treatment, care and health advice.

Caring for millions of older people is indeed a challenge – but if we are prepared to value care, and design services with the intention of maximising health as well as dealing with the consequences of illness, there are opportunities here to keep people well and independent. To take those opportunities, the system needs to work together, and it needs to be refocused. We need to have a sophisticated understanding of costs and benefits, and the RCN is working with OPM to ensure that the costs and benefits of nursing are fully understood. That way, decisions can be taken on the basis of long term health gain, not short term cash savings.

In other ways, we are dealing with the consequences of failure – of health inequalities which mean that young people in some communities have health not much better than when their ancestors worked in heavy industry and could expect to die in middle age. These problems go far wider than health – there are spirals of deprivation which mean that generations are afflicted by low pay, poor diet, and low aspirations which rob people of the motivation to live better lives.

In both cases, the expertise and opportunity exists to make public services better using the skills of professionals such as nurses. Meeting the needs of the older generation is complex and requires skill – but the skill does exist if we are willing to invest the resources. And we know how to help people to lead healthier and more productive lives – but again, we have to be willing to grasp the opportunity, and take the time to help.

With the political will to make it work, the public sector has many things going for it – professionals who spend their lifetimes working to care for people, and who are committed to finding the best ways to help with the resources available. We know what good interventions look like in the public sector – experts work together without territory, whether it is through education, welfare, child protection or crime prevention.

Many public services have existed for almost a century now, and like the rest of the developed world we have learned a lot. We should be better at learning the lessons of history, and of sharing experiences between sectors, but already the public service ethos is deeply ingrained and it is a great asset.

Nurses, like other professionals who deliver public services, represent excellent value for the work they do – even with the modest pay increase proposed by the independent body but denied by the government. A recent report by the Commonwealth Fund showed that the UK NHS represents the best value in the world.

Health staff have more to offer than just their labour. They have the expertise and commitment to design services to meet future needs, to advocate for the people they care for and to promote better lives to all their patients. This is true whether their patients are from the parts of the country where they can expect to live to 100, or the areas where their life expectancy has not significantly improved for generations.

To do all those things, the NHS does not only need to pay them. It needs to empower them, value them and listen to their experiences. Collectively, the answers to the current challenges are contained within those who have dedicated their lives to making public services better, it just requires a concerted effort to bring it out.

Dr Peter Carter is Chief Executive & General Secretary of the Royal College of Nursing (RCN)


About the series

OPM is celebrating its 25th anniversary this year, and as a public interest organisation, we’ve always contributed to the debate about the future of public services.

With this and the next general election in mind, we’ve asked a number of senior thinkers to give their views on the challenges and opportunities facing public services and society in the near future.

This is one of a series of guest blogs, which we’ll be adding to in the coming weeks and months. To read previous posts in the series, go to our news and comment page.

Thursday, September 4, 2014

Hate crime: new insights, new solutions

On Friday, 5th September 2014, the Leicester Hate Crime Project will be launching the report of its two-year research into acts of hate, prejudice and targeted hostility at the end of project conference. It promises new insights into the nature and forms of these acts and their impact.The team has been able to expand upon the range of victim groups and experiences typically covered within conventional studies of hate crime, thereby giving a voice to victims who have tended to be peripheral or ‘invisible’ within research and policy.

The project team is keen for the research to have a tangible impact on policy and practice. The conference itself includes a substantive segment on ‘identifying solutions’. This is where I have been invited to speak as part of a wider debate touching on the implications for policy and practice.

I have been fortunate in having the opportunity to work at the nexus of evidence, policy and practice; and have supported a number of police services and local authorities to improve systems and response. More recently, my efforts have focussed on the role of healthcare agencies in supporting hate crime victims and helping to prevent hate crimes. This will be the focus of my presentation on Friday.

Why healthcare?

Treatment and support

First, hate crime victims suffer a range of physical and/or mental harms. Healthcare agencies have an obvious role in treating and supporting victims. Their response is, however, lacking. While most, if not all, hate crime victims require some form of mental health support, referral to such support is not always enacted by healthcare professionals in primary care (e.g. general practitioners) and acute care settings (e.g. Accident and Emergency).

In addition, the healthcare response is often strictly in terms of the clinical treatment of the condition or symptom the patient is presenting with (e.g. physical injury). Victims of hate crime rarely get referred or signposted to services and support that help promote holistic recovery and wellbeing.


Second, the health service does not as yet sufficiently recognise that it has a role in helping to prevent hate crime. There is still a widespread perception that it is a matter for the police. By only treating the direct physical and/or mental symptoms stemming from having experienced hate crime, healthcare professionals often do not link up with the police. Hence such incidents are not recorded, and remain invisible.

Healthcare agencies can play an important role in picking up early signs of (repeat) victimisation through sub-criminal incidents that have significant impact on the victim’s mental health, and are corrosive over long periods of time. We cannot adequately tackle hate crime until we look at the issue of hate incidents, as the evidence tell us that the latter often escalate into the former if not dealt with. From the healthcare perspective, conditions such as stress, depression, hyper-tension, etc. may be symptoms of ‘something else’ happening in victims’ lives.


Third, as healthcare is a caring sector, we can overlook the fact that healthcare settings may enhance risk and some professionals may actually be perpetrators of hate crime. In recent years, high profile scandals in care homes and other institutionalised care settings have drawn attention to this fact. There is growing recognition of the need to treat these as hate crime rather than simply ‘care failings’ or ‘abuse’. In the Winterbourne View hospital scandal, for example, treating the events as hate crime allowed the sentence to be uplifted using Section 146 of the Criminal Justice Act.

Towards a hate crime care pathway

Leicestershire has been amongst the first areas to respond to the challenge to get the health service to acknowledge its multiple roles in relation to hate crime. Recognising both the ‘victim’s journey’ and the conditions that healthcare professionals work under, a hate crime healthcare pathway is being developed by bringing together victims and agencies in the statutory and community sectors to explore how the various components may be joined up without undue burden to healthcare professionals while providing victims with seamless care. Tackling hate crime requires effective multi-agency response. Key partners in health, social care, housing, and education all have a role. Leicestershire Partnership NHS Trust and its partners should be congratulated for its vision, and commitment to an issue that can so easily fall off the radar when money is tight.

Monday, September 1, 2014

25th anniversary guest blog series: Self-supporting and strong communities can be key to tackling isolation

My Mother died ten years ago. She received home care services that supported her to get up in the morning. This in turn helped her to go across the road to the local primary school and do sessions with the young children; she told them about what life was like between the wars. This experience helped her retain her own sense of worth, it was good for the school and it benefitted the wider community too. The moral? Let’s see services that remove barriers to active participation, and never as just ends in themselves.

I’d like to see the development of more safe, strong, self-supporting communities. Gone should be the days when we’d tick the box that says: ‘social care; done’, especially if that means that someone was bussed to a day centre miles away from home for the day, only to return to a life of isolation.

I did qualify my statement above by saying “MORE safe, strong, self-supporting communities”, because of course excellent examples exist already. There are, and always have been, individuals and groups within communities, formal and informal, who, with a minimum of fuss, provide all sorts of help and support to those who need it; and friendship too.  But undoubtedly there is more to do, especially given the unprecedented financial constraints under which service providers are now operating.

One of our films on Social Care TV looks at isolation in Dorset and how it’s being addressed. It introduces Brian, who, in the film, has recently lost his wife and says that he didn’t much care, if he was crossing a busy main road, whether he got to the other side or not. But by being encouraged to go to a local tea dance, Brian is shown to be healthier, happier and less isolated.

The Guardian newspapers says the problem of social isolation is so severe that they’ve included it as one of the five modern giant evils that must be tackled by people working in the public and voluntary services. A recent Guardian panel of experts, including a colleague from SCIE, discussed how professionals from local government, social care, healthcare and the voluntary sector can work together in tackling isolation.

At SCIE we’ve produced an At a glance guide to older people and isolation. In it we said that, as the UK’s population rapidly ages, the issue of acute loneliness and social isolation is one of the biggest challenges facing our society. It’s a moral and financial necessity to address it, for the sake of both the people concerned and the wider community. And let’s also remember that carers can also be isolated, so their needs should be addressed.

Let’s start to remove barriers to people having active citizenship roles. They may need to have the appropriate care and support to achieve this, but it’s worth it, surely? I know it was for my Mother.

Tony Hunter is Chief Executive of the Social Care Institute for Excellence (SCIE)


About the series

OPM is celebrating its 25th anniversary this year, and as a public interest organisation, we’ve always contributed to the debate about the future of public services.

With this and the next general election in mind, we’ve asked a number of senior thinkers to give their views on the challenges and opportunities facing public services and society in the near future.

This is one of a series of guest blogs, which we’ll be adding to in the coming weeks and months. To read previous posts in the series, go to our news and comment page.