NHS Confed supplement June 2012 - Health Service Journal


NHS Confed supplement June 2012 - Health Service Journal

AN HSJ SUPPLEMENT/14 JUNE 2012hsj/nhsconfederationsupplementsecretservicewhy whistleblowingshould be encouraged,not punished 15

AttentionpsychologistsIMPORTANTRegister before1 July 2012If you are currently practising usingone of the titles below and arenot registered with the HealthProfessions Council (HPC) youmust register immediately.From 1 July 2012 these titles will belegally protected and anyone usingthem must be registered or they willbe committing a criminal offence.• Clinical psychologist• Counselling psychologist• Educational psychologist• Forensic psychologist• Health psychologist• Occupational psychologist• Practitioner psychologist• Registered psychologist• Sport and exercise psychologistFor more information visitwww.hpc-uk.org/grandparentingor call 0845 300 4472Park House184 Kennington Park RoadLondon SE11 4BUProtecting the publicRegulating health professionals

CONTENTSEVENTSINSIDEhsj.co.ukSub editorCecilia ThomDesign Judy SkidmoreLEADERSHIPMEDICAL IMAGINGCurrent PACS contracts are coming to an end so trusts must look at the different storage solutions onoffer and ascertain what they want and need to operate effectively. Page 6Mike Farrar, chief executive of the NHSConfederation, talks to Alison Moore about theneed to focus on making the Health and SocialCare Act work in practice, and what must betaken into consideration. Page 2PARTNERSHIPSNursing home care for older people can be improved and hospitaladmissions reduced. During this HSJ roundtable, healthcare leaders lookedat the ways of achieving these goals, the benefits of partnership workingand what the concept of working in partnership really means. Page 10WHISTLEBLOWINGBeing aware ofsubstandardhealthcare practices iscrucial to makingimprovements thatwill benefit patients.Although changes inlegislation are useful,organisations mustalso adapt the cultureof their workplace sostaff are encouraged toreport bad practice.Page 15DATA MANAGEMENTAs more and more healthcare information goes digital, innovative solutions are needed to ensuredata can be stored, safeguarded and accessed effectively. Page 18SERVICE PROVISIONContracts may be signed in good faith, but achange in circumstances can mean a provider isno longer able to fulfil the terms of its contract.Knowing how to prepare for, and deal with, suchevents is invaluable. Page 23hsj.co.uk 14 June 2012 Health Service Journal supplement 1

HEALTH AND SOCIAL CARE ACTFROM ACTTO ACTIONNow the Health and Social Care Act has cometo fruition, it’s time to focus on how to make itwork in practice, Mike Farrar tells Alison MoorePragmatism is the order of the day for theNHS now the Health and Social Care Acthas been passed. The divisions of the lasttwo years have had to be put to one side asmanagers and clinicians face the task ofputting the changes into practice.Mike Farrar, chief executive of theNHS Confederation, is a man made forpragmatism. A constructive critic of thebill, he has managed to remain on goodterms with all sides despite the bitterdebates, and is acutely aware that NHSorganisations will have to implement andmake sense of the coming changes. If hethinks it’s a pig’s ear of an act, he is toodiplomatic to say so.“It’s now down to us,” he says. “Whateverpeople think about the rights and wrongs ofthe legislation...we have to make thearchitecture work for the benefit of thepatients.”He sees opportunities in the overall visionof the bill, one of which is the ability toconnect with people about their own healthand lifestyle factors. This includes areas likeexercise, which he is passionate about.A ‘good’ resultAnother is around engaging and explainingwith the public about what is a “good”outcome for a health service. That is likely tobe keeping people out of hospital ratherthan obsessing about the size of hospitals,and looking at the outcomes of treatmentrather than where that treatment is provided.“We need to be much more proactive,” hesays. “When we talk about these thingsreactively we almost put the public andpoliticians on the back foot…it looks likethese changes are being forced on them.”Talking about variation and seeking thebest outcomes is part of this.“Can we be more transparent so peoplecan see variations in outcomes and push usso we have to deliver the best everywhere?”Despite the heavily politicised nature ofthe debate around the bill, he believes allparties accept change has to come. But is itthe way the debate is framed in the UK thatcauses some of the problems? The Dutch talknot of reconfiguration but of ebb and flow,seeing changes as a two way process, he says.Some services move further away, but othersare provided closer to home.He gives an example from the North West,where he ran the strategic health authorityfor many years. The people of Rochdale areconcerned about the loss of services at theirlocal hospital but there has been far lessfocus on the way in which some services aremoving closer to them – for example, theChristie Hospital will be operating twolinear particle accelerator machines at aJAMES ROYALL2 Health Service Journal supplement 14 June 2012hsj.co.uk

ADVERTISEMENT FEATUREA matter of life and deathEstablished in 2008 to ensure all adults nearing the end of life have access to high quality care, theNational End of Life Care Programme (NEoLCP) has made significant progress over the past fouryears, developing on previous work which supported Building on the Best (DH, 2003). Claire Henryassesses the challenges facing the programme and its achievements so far.Established in 2008 to ensure all adultsnearing the end of life have access to highquality care, the National End of Life CareProgramme (NEoLCP) has made significantprogress over the past four years, developingon previous work which supported Buildingon the Best (DH, 2003). Claire Henryassesses the challenges facing theprogramme and its achievements so far.It’s a stark reality that many people do notdie in the place of their choice - usually theirhome or a hospice - or have a ‘good death’free from pain and distress. For example in2005, 58.3% of deaths were in hospital,which may not have been the choice of thedying person or the best use of hospitalresources.The End of Life Care Strategy for England(DH, 2008) was the catalyst for bringingSystems (EPaCCS)• e-Learning courses via e-ELCA• ‘Route to Success’ guides for specificsettings and professions (acute hospitals,care homes, nursing, ambulance services)• Care after death and developingbereavement services.The quality outcome can be measured by theproportion of people who die in theirpreferred place of care. By 2010, the numberof deaths in hospital had fallen to 53.3%.The percentage of deaths in the usual placeof residence is rising, from just under 38% to41.5% in the first three years of theprogramme. A dedicated ‘1%’ campaignworking with GPs and other partners aimsto maintain this improvement.InnovationInnovation too has played a key role. Forresult in a saving of £52m (CMG42 Guide forcommissioners on end of life care for adults,NICE 2011). Similarly, a 10% reduction inbed days for a person who is in hospital formore than eight days before death couldsave around £57m – assuming a cost per bedday of £200 (QIPP Reviewing end of life carecosting information, NEoLCP 2012).PreventionWorking with around 40 individuals fromseven PCT areas which were performingwell in terms of preventing people fromdying in hospital if this was not their wish,we were able to identify nine critical successfactors.These ranged from strong commissioningand clinical leadership, use of nationalpayment incentives plus flexible jointbudgets and care packages to use ofnationally recognised tools, clearly definedaccess to 24 hour cover, development of carehomes, co-ordination of care acrossprofessional/organisational boundaries andtraining.End of life care pathway. Adapted from End of Life Care Strategy (DH, 2008)about a fundamental change in policy.Developed in partnership with 300stakeholder groups and organisations, thestrategy gave the NEoLCP responsibility fortranslating this new approach into practice,supporting and enabling staff and employersacross health, social care and third sectororganisations.The NEoLCP is not simply a co-ordinatingbody or networking group. It is rooted in theQIPP agenda as a core workstream, and hasto meet performance indicators and delivervalue for money.So how have we fared in delivering quality,innovation, productivity and prevention?QualityTo get consistent quality of care delivered inevery setting – home, hospital, community –a number of strands have been woventogether to support transformational change.These require multiple key interventionsworking together across a whole system andinclude promoting best practice in areas suchas:• Communications skills• Advance care planning (ACP)• Recording and sharing informationeffectively between various agencies viaElectronic Palliative Care Co-ordinationexample, in 2010 we launched the NationalEnd of Life Care Intelligence Network(NEoLCIN). By consolidating, analysing andsharing data about age, place and cause ofdeath, NEoLCIN has helped commissioners,providers and policymakers to make majordecisions about end of life services.New approaches to joint working haveproved invaluable. Truly co-ordinated carefor people at the end of life involves socialcare as well as NHS professionals and thevoluntary sector. NEoLCP brought togetheran expert working party in 2010 to develop asocial care framework. It maps out howsocial care commissioners and providers,together with those involved in training andeducation, can boost the contribution ofsocial care to overall end of life care.ProductivityProviding the best care for the dying personand their family also leads to productivityand efficiency gains. Unnecessaryemergency hospital admissions in the finalyear of life, delays in discharging peoplehome to die in accordance with their wishesand inappropriate or unwanted interventionshave a financial as well as a human cost.In England, a 10% reduction in the numberof hospital admissions ending in death couldTo give just one illustration of some of thesefactors in practice, in County Durham twoMacmillan discharge facilitators received181 referrals in five months. Some 80% ofthe people referred died in their preferredsetting.Death may still be a taboo subject in society,but those responsible for providing care atthe end of life need to speak out loud andclear. With significant changes to the waythe NHS commissions services currentlybeing implemented, improvements in carequality which in turn generate cost savingsare a priority.End of life care could be a blue print for howa structured, co-ordinated approach candeliver both better quality and more costeffectivecare. It really is a matter of life anddeath.Claire Henry is Programme Director of the National End ofLife Care Programme (www.endoflifecareforadults.nhs.uk)and also Joint National Lead for the Department of Health’send of life care QIPP workstream.

satellite site in Oldham, saving manypatients from that area having to makerepeated trips to its main site.“We somehow only get the debate aboutservices moving further away. We know a lotof diagnostic tests and equipment are notonly moving closer but are coming to thehigh street,” he says. “We can deliver thingsin your own home which, 20 years ago, youwould have had to go to hospital for.”And he sees clinical involvement as auseful means to help the public understandsome of these messages. “It’s not just themessage, it’s the messenger,” he says. “Weknow how well trusted our colleagues are.That is one of the great opportunities ofhaving them engaged in management.”While simply saving money may not bethe natural territory of clinicians, improvingservices and reducing variations is. But MrFarrar says the NHS does need leaders whoare more upfront about managing theirorganisation as a healthcare business.He has an unfashionably Keynesianapproach, suggesting the NHS could have arole in regeneration, and investment in itsinfrastructure could be helpful in the currentfinancial situation. “We should becampaigning quite hard to get thegovernment to invest in infrastructurebecause it is so cheap at the moment... TheNHS could kickstart through governmentinvestment in infrastructure.”But the taxpayer should not be asked tokeep on paying for inefficiency, he says.Looking to the futureThe next few years will be incredibly difficultand will require more efficiency savings. Hesays a lot of work has been done withinorganisations to make savings – but thefocus must now move towards collaborationas the ability within single organisations tofind yet more savings may “run out of road”.“It is in the boundaries of healthcare thatwe will find savings – for example,community to primary care, hospital tohospital and health and social care,” he says.“All of these areas where there is a boundaryare probably where you get systemic savingson a scale necessary to solve the problem.”Getting more productivity out of theworkforce – albeit in a way that is fair – isanother part of the solution, he says. “Thereis a trade off – amount of labour versus costof labour.” How to motivate people to workin what Farrar calls “the greatestorganisation in the world” is another part ofthis, and here he is concerned about howmanagers are treated. Manager bashing is“short sighted” he says.“This is about understanding that to getgreat quality outcomes you need to organisecare well and spend money properly.Belittling the money you spent onorganising care, and then saying you onlyvalue those who deliver care, will get youpoorer outcomes.”There’s widespread scepticism, evenamong clinicians, that the reforms willcause the government to withdraw from itscentral role in healthcare in favour of localsolutions. He says it will still have a big roleand needs to make sure all the elements are‘Whatever people thinkabout the rights andwrongs of the legislationwe have to make thearchitecture work for thebenefit of the patients’aligned. Commissioning is just one ofthe levers.He highlights as important the drivetowards integration and the need forMonitor to work in the public interest. Andhe admits he is optimistic about the future.Finances may still be difficult in five years’time he says, but there could beunderstanding of the need for change andthe value of clinicians in management couldhave been unlocked. “I think we will bemoving forward,” he says.But where will the NHS Confederation fitinto this? Over the last few years its futurehas seemed uncertain – the divergence ofthe Foundation Trust Network nearly led toa complete split and the coming of clinicalcommissioning groups, with the tendency ofGPs to look towards other representativeorganisations, may diminish its role on thecommissioning side.Mr Farrar says providing a place wherethe industry can come together is veryimportant. It can also provide thoughtleadership and vision. “We have to moveforward from some of the issues that we hadin the last five years,” he says.The Confederation is now working withthe NHS Alliance and the NationalAssociation of Primary Care in a newumbrella organisation – NHS ClinicalCommissioners. Support from theConfederation has been “received warmly”he says, and he is at pains to point out thatas a former head of primary care at theDepartment of Health he does know thefield well.But he thinks the areas in which theConfederation can really score is in bringingtogether people from all sides of healthcarein a way that adds value and weight. There isless of the ‘they would say that, wouldn‘tthey?’ reaction because of this diversemembership, individuals of which may havedifferent perspectives on key issues.“We have not just got the providers in theroom. We have NHS and non-NHSproviders, mental health trusts…all workingthrough these things together. TheConfederation is a ‘community of interests’,”he says.But it has to deliver value for its members.“I’m pleased with progress but notcomplacent,” he adds.So what for Mr Farrar now? The man whostarted as a hospital gardener (and had apromising career in professional sports ruledout by injury) has now done some of thebiggest jobs in the NHS. For the moment, heseems content to lead the Confederation.Commentator Roy Lilley has rathermischievously suggested he could lead theCare Quality Commission but Mr Farrardismisses the idea. “I don’t think mystrengths are as a regulator but I can thinkof some very good people who could do it.”Above all, Farrar seems to have pride andgain an enormous amount of enjoymentfrom working for or with the NHS. Hewould have no hesitation in recommendinga career in it to his children.“I can honestly say – and I do say – I havenever had a Monday morning where I havethought I don’t want to work in thisorganisation any more. I’ve always believed itwas one of the world’s best creations…peopleshould feel privileged to have an opportunityto work at senior level,” he says. ljames royallhsj.co.uk 14 June 2012 Health Service Journal supplement 5

matt oaKLeYon image storagein association with accentureAs the national contracts for picturearchiving and communicationssystems (PACS) come to an end, NHS trusts arereviewing their medical imaging services andconsidering their options. In doing so they arefacing an unprecedented set of challenges, froman explosion of data to the lack of resourcesavailable to manage and report it effectively.With no centralised procurement body tomanage this on their behalf, many trusts arecoming to market alone or as mini consortia.Other than for those with scale, this is puttingsignificant pressure on providers to respond.What we are seeing emerge from all of this isa shift to localisation in terms of decisionmaking and solution choices. This is counter thetrends we see around the world where, in linewith other industries, health organisations arelooking to leverage investments made to date,scalable operations and modern technologysolutions such as cloud.This is an important consideration and,while a shift to local decisions and contractsmay be vital to the delivery of high quality localcare, it should not necessarily default to localsolutions. The end of national contracts doesnot mean trusts should forgo the manyadvantages that come through a fully managedservice from a proven and trusted supplier, andthe investments the NHS has itself made instanding these services up in the first instance.‘We’re seeing a shift tolocalisation, which goesagainst world trends’Scale is the key to this. A fully managedservice offers highly competitive pricing andthe lowest total cost of ownership (TCO)through the scale and efficiency of operations.It also means peace of mind – trusts can leavethe end to end management of their service toteams experienced in delivering againstbenchmark service levels over several years –and technology can be reduced or removed fromthe care setting leaving trusts to concentrate ondelivering the best care to patients.Accenture is committed to providing lowestTCO and outstanding end to end service. Our oneyear contract extension for PACS means we canoffer continuity to trusts in this time of change.Building on this we intend to be a market leaderin medical imaging for the long term.We’re investing in innovation by extendingour operations in the Central Data Store toinclude a cloud based Vendor Neutral Archiveand developing a revolutionary PACS in thecloud. We’re also working with leading PACSsuppliers to offer trusts the solution that’s rightfor them. Choice, together with end to endservice excellence, innovation and lowest totalcost of ownership, are what trusts need in thisbrave new world of medical imaging.Matt Oakley is medical imaging leadat Accenture. www.accenture.commeDicaL imagingthe biggerpictureas current PaCS contracts come to an end, trusts needto work out exactly what they want and need their newstorage solutions to deliver, explains alison mooreEvery year millions of patients in hospitalwill have images taken that are critical totheir diagnosis and treatment. Storing andsharing these images is made possible bypicture archiving and communicationssystems (PACS), which have become anintegral part of how trusts operate over thelast decade. However, with the currentPACS contracts coming to an end in 2013and 2014, trusts will have to make decisionsabout what their needs are going to be inthe future and how these can be best met.It is almost unprecedented for all NHStrusts to be thinking of reprocurement ofsuch a major service at the same time; inaddition, this comes at a time when thetechnology available has moved ondramatically. Although the existing PACSsystems were usually provided through theNational Programme for IT, with a numberof local service providers being selectedthrough a tender process, this time, trustswill be on their own and have greater choiceover what they can procure.The contracts with local service providersend for most strategic health authorityregions on 30 June 2013 and for London ayear later, with a two year transition periodafter this. Trusts in the regions served byAccenture will be able to take advantage ofan extension to their contracts, enablingthem to stay with the same provider until2016. But, sooner or later, all trusts willhave to start thinking about a new contract– and that means looking at how theirfuture needs may change.Imaging in the NHS is still developing.Both the number of images being taken andthe complexity of these is increasing year onyear. And while imaging was once seen onlyas the fiefdom of the radiology department,it is now used across hospitals in otherdepartments such as dental and cardiology.“The vast majority of trusts went fromwet film to a PACS service through thenational programme,” says Matt Oakley,Accenture’s medical imaging lead. “They didnot have to think about the contractsituation at all because it was dealt with bythe National Programme for IT.“Now we are seeing a seven to eight percent increase in the number of images takeneach year for each of our current customers,plus an 18 per cent increase in the size ofstudies.”So what should trusts be thinking about?The first decision is probably whether to rollover their existing contract if this option isavailable. This will give them security ofprovision – often at a reduced price – plusextra time to decide on a longer termsolution. Accenture says around threequartersof its existing clients across threeSHA areas (East of England, East Midlandsand the North East) have already agreed todo this and others are considering it. Therollover that has been agreed will seeAccenture continuing to run its central datastore until June 2016.But for trusts that do want to retenderthere are lots of issues to consider. One isthe involvement and support of clinicians –the end users of any system who often havestrong views about how the existingprovision is doing and the specification forany new system.“Medical imaging is so important to atrust that clinical directors should beinvolved,” says Mr Oakley. “It is all aboutmaking sure you have the service that willbest enable you to give the best care topatients.”But he stresses the evolving role ofmedical imaging across trusts and the needto get perspectives from different specialtiesthat may be using it.And the technology available has movedon dramatically in the last few years.Whereas trusts used to think in terms ofinfrastructure and staff for any PACSsystem being sited in their IT department,around the world many healthcareorganisations are storing both digitalimages and the PACS software in the cloud.6 Health Service Journal supplement 14 June 2012 hsj.co.uk

case STUDIES OVERLEAFA radiographer usesa computer to look atan X-ray in a hospitalThis means trusts no longer need banks ofservers to run the system – and therefore nolonger need to employ specialists tomaintain them.“A bank does not spend its own timeworking out how to run data storage,” saysMr Oakley. “Someone else does it. The sameshould be true of a hospital – it’s not its corebusiness.“This is where the rest of the world isheading, there is no reason why the NHSshould not take advantage of it as well.”Healthcare organisations are alreadyreaping the benefits of a cloud based PACSsystem, he says. These include reducedinfrastructure costs, a smaller onsitehardware and software footprint, resilienceagainst systems failure, enhanced operationefficiency and faster implementation.From a clinician’s point of view, cloudbased systems can make sharing imagesand viewing them remotely easier. They canbe accessed where and when they areneeded – which can support remoteworking. This can be useful for trusts tryingto provide services on a limited rota or outof hours. Scans of people with suspectedstrokes, for example, can be accessed byconsultants from home (provided they havea standard broadband connection) and staffin hospital told what action to take. Thiscan both speed up decision making – to thebenefit of patients – and reduce costs.Trusts may be concerned about the riskto data protection with cloud basedsystems, although this has not proved to bean issue in the rest of the world. Systems‘While imaging wasonce seen only as thefiefdom of the radiologydepartment, it is nowused across hospitals inother departments’with centralised data have governancesystems and data protection to protect theirclients.Mr Oakley urges finance directors, whoare likely to have a key role in procurementdecisions, to look at costs and benefits overthe whole life system of a service or piece ofequipment. This can include savings fromquicker readings and reduced out of hourspayments.Trusts may also want to look at buyingin collaboration with other organisations.One clear advantage of this is it can reducethe burden of procurement, which canbe time-consuming – many PACSprocurements will need to go through theOfficial Journal of the European Unionprocess. Another is that aggregated buyingcan often reduce costs.But timing may also be important. Withthe unusual position of so many trusts goingto market within a short time, suppliers willbe under pressure and may have capacityissues. Responding to tenders can be timeconsumingfor them as well – one recentprocurement involved more than 1000questions that bidders had to respond toand procurement staff had to evaluate.Collaborative tendering could help providersrespond to more tenders and could lead tocheaper solutions for trusts.With such a crucial service involved, MrOakley urges boards to stay abreast of thetrust’s plans for future procurement. “It isgoing to be a relatively significant risk thatthey are managing. It’s not just a financialrisk, it’s a clinical risk,” he adds. lalamyhsj.co.uk 14 June 2012 Health Service Journal supplement 7

in association with accenturemedical imaging: case studiesfocus on theright thingChoosing an image storage solution that suits the needsof clinicians and finance personnel means knowingwhat is important to both parties, says Alison MooreThe finance director’sperspectiveAaron Cummins is finance director at theLiverpool Heart and Chest HospitalFoundation Trust, chair of the FoundationTrust Network’s finance director forum andchair of the Government ProcurementServices NHS Customer Board. Centrally ledprocurements may not be flavour of themonth, but Mr Cummins says the situationover the procurement of picture archivingand communications systems (PACS) hasshown it does have some advantages.The centrally led procurement processworked well last time, he says, and thoseresponsible for procurement are now askinghow they maintain value and leverage intrying to get their own solutions.“We are all having to say what does thismean for us. Some organisations are goingto go on their own but many areas arecoming together to go to the market as agroup. In some cases, that might be threeorganisations but there are as many as 11,”he says. With so many procurements beingcontemplated at the same time “it iscertainly not the greatest position to be in.”Mr Cummins is clear this needs to be aclinically led procurement, as it is integral topatient care. “The radiology functionsupports the whole hospital. You need ITsavvy clinical leaders involved – and theremay not be enough of them.“The radiology lead will have a view ofthe specification but so will the cardiologylead, for example.”In terms of the procurement, he thinksorganisations within the local healtheconomy could come together to commissiondata storage together. But he senses somenervousness about cloud based storage.“The cloud still makes people nervous. Asa concept it is absolutely right. You only payfor what you use. But finance directors andIT directors still like putting their hands on apiece of tin and knowing if it goes wrongsomeone will be there within the hour.”Data protection can still be seen as moreof an issue with remote storage, he says, andtrusts are anxious about this – especially asthe Information Commissioner’s Office canimpose massive fines. One solution is ahybrid where there is a private cluster ofdata but this can be more expensive.The solutions that trusts adopt willdepend on their circumstances, he says,suggesting trusts with plenty of capital butconcerns about future revenue may behappier to pay more of the costs up front.Trusts that are short of capital, however, maylook at different solutions and be happier topay costs out of an ongoing revenue stream.“It could come down to a financial modelthat is more attractive, but I would besurprised if finance trumped governance,”he says.The radiologist’s perspectiveDr John Somers is a consultant atNottingham University Hospitals Trust,specialising in paediatric radiology. It iscommon to find doctors who are critical ofnational procurements; while Dr Somershas few criticisms of the original PACSprocurement, he is concerned the currentreprocurement could lead to fragmentation.The current PACS system he uses hasbeen “pretty good” he says, although he hashad more concerns about the radiologyinformation system (RIS), which wasprocured separately, and voice recognition.“As a radiologist I would like to see thesethree elements tightly integrated in a singleenvelope with someone responsible forkeeping them all working,” he says. “I don’tsee that there is any appetite to go through areprocurement of PACS in the near future.”Changing systems can be disruptive andrequires many staff to learn a new system.What he does want to see, though, isprogress on improving systems andemphasis on the seamless electronic transferof information between hospitals.“If we go to piecemeal trust basedprocurement of different PACS systems, whois going to look after image sharing? We aredeveloping trauma and cancer networks butwe are going to locally procured solutions.”Fragmentation of the system could affectthe viability of some providers and also leadto difficulties in sharing images, he says. “Iwould not like to buy a PACS system andthen an RIS system and then an imagesharing system.”As one of a few specialists in paediatricradiology in the country, he is often asked toassist with interpreting results taken in otherhospitals. These can be of seriously illchildren, where a second opinion is needed,or cases of suspected non-accidental injury.With some of these, time is of the essenceand his reading of the scan can have seriousconsequences such as affecting whether achild is allowed to go home with parents oris taken into care.Dr Somers currently reads images sentfrom Peterborough City Hospitalelectronically and can often respond withinan hour. He gets a text message to alert him8 Health Service Journal supplement 14 June 2012 hsj.co.uk

a scan is being sent; if more hospitals wereable to send scans as easily as Peterborough,he believes Nottingham could start toprovide a 24/7 service across a wide areaand give specialist input like this to otherhospitals receiving sick children.And systems that allow smoother widersharing of images could also improve care.For example, trusts could collaborate toreduce times when a department is underpressure and reading is delayed. Severaltrusts could work together to smooth outthe work and get images reviewed quicker –something that could benefit patients. “Thisis something that could be developed butonly if you had a regional supplier,” he adds.The central perspectiveProfessor Erika Denton is the nationalclinical director for imaging at theDepartment of Health and the seniorresponsible officer for the national PACSprogramme. Mary Barber is programmedirector for PACS at Connecting for Health.Trusts need to be making decisions nowabout what happens when their centralPACS contracts expire and ensure theyknow what they want to buy if they are notextending their contracts. That’s theTrusts will have to work out whichPACS solutions best meet the needs oftheir various departments and teams‘If we go to piecemealtrust based procurementof different PACSsystems, who is going tolook after image sharing?’message from Professor Erika Denton andMary Barber. They have worked withindividual trusts to ensure they know whentheir current contract will expire and theoptions that are available to them.These options include “going it alone” tocommission a new system – “perfectlyreasonable” says Professor Denton –procuring with neighbouring trusts, andextending their current contract whichallows them some breathing space andcould also prevent the market becomingswamped. But where trusts in the same areaall want to procure, it would be crazy forthem not to work together, she says.She highlights that NHS Supply Chainhas a national framework around PACS,which ensures that suppliers already meetgovernance standards.Ms Barber points out there mightnormally be five to eight Official Journal ofthe European Union procurements for PACSsystems each year. The ending of thenational contracts means there werepotentially 128 trusts procuring in a shorttimespan. However, around half of thosehad started reprocurement by March andanother 23 had taken out an extension totheir existing contract.She encouraged trusts to be aware ofhow PACS has moved on in the last fewyears and the lower cost of storage now.“But they are still fundamentally a big filingsystem,” she says. In addition, she urgestrusts to remember there could be morebenefits to come from PACS. “We say totrusts we know this is tough. But thinkabout the vision. Do we want radiology inprimary care but reporting in secondarycare, for example?”“We are not going to be proscriptiveabout how local institutions procure PACS,”says Professor Denton. “How they storeimages will be up to local trusts. But we dodictate the standards for that storage.”Trusts are expected to procure in line withthose standards but the choice of whetherthey have solid state storage or cloud basedis up to them she says.Ms Barber points out that data is alreadystored outside the boundaries of theorganisation, through the existing centraldata storage system. “The technology isalready out there and in proven use,” shesays. “Some of the newer technology takesus a little bit further.”But the issue is less about where data isstored and more about the controls aroundinformation governance, which ought to bein place – including multiple copes of dataand arrangements for disaster recovery.So are there are worries about theprocurement? Although they are supportiveof local ownership, Professor Denton and MsBarber say the danger is that silos develop.They have already written to chief executivescurrently using centrally procured systems towarn them of the need to get involved. “Wehave told them that the risk is their risk. Weare doing all this but the decisions are forthem to make,” says Professor Denton. Theletter says trusts should be reporting thepotential loss of PACS and the associatedsystems in their risk logs.Professor Denton says the NHS systemhas become dependent on PACS since thecurrent system was brought in between fiveand seven years ago. Any interruption inPACS would have massive consequences –as a result, the current system will have torun in parallel with any new systems thattrusts adopt while data is transferred.Ultimately the old system can be turned off,but trusts will be anxious to avoid anyinterruption in what has become anessential clinical tool. lalamyhsj.co.uk 14 June 2012 Health Service Journal supplement 9

Roundtable: partnershipscollaborateand conquerPartnerships are vital to providing effective nursing home carefor older people and reducing unnecessary hospital admissions,but working together means more than just being at the samemeeting, as this HSJ roundtable proves. Daloni Carlisle reportsThere is an assumption thatnursing homes provide onlylong term care. But is this true?And if not, how can the NHSwork with the care home sectorto develop and commissioninnovative services using shorterstays to support older peopleand keep them out of hospital?Barchester Healthcare hasworked with the NHS for manyyears and in many places to offeralternatives to acute care,developing approaches toprevent admission to hospitaland support earlier discharge.These include re-ablement beds,short term intensive nursingcare for people with Alzheimer’sdisease or bringing primary careservices into care homes.Barchester, and others, havedemonstrated clear savingsthrough reduced length of stayand avoidance of unnecessaryadmissions as well as improvedquality of care. In each case,success hinged on partnershipbetween the NHS, social careand the care home provider.Rather than explore the specificexamples of these, chairmanMike Sobanja first focused onexploring their characteristics.What did they look like? Howcould they best be made to work?Stuart Bain, chief executive ofEast Kent Hospitals FoundationTrust, was upfront about whatpartnership meant to him inthis context.“To have a healthypartnership you need to be clearabout the outcomes each partnerwants separately, what they wantto achieve together and how youmeasure outcomes. If you don’thave a clear scope at thebeginning, there is the potentialfor it to creep,” he said.“For ourselves, we are very,very clear about what addedvalue there will be frommanaging the care differently fora particular group of patients.We are very clear about thecriteria for selection, theexpectations we have about howquickly someone will be movedon and how long they will be inthat care setting. We carry outretrospective reviews every threemonths.” The upshot of thatclarity was a growing level oftrust and knowledge betweenthe partners, he added.Know your partnerRobert Flack, chief executive ofLocala Community PartnershipsCommunity Interest Company,which provides community careservices for people in andaround Kirklees, said thisintimate knowledge of differentservices’ working processes wasan important factor.“It is something that is oftenmissed,” he said. “A ward basednurse says ‘this is the care home’sresponsibility’ but they may havevery little understanding of thecare home’s role. Sometimes thesimple measure of getting peopletogether in a room will helpdevelop that understanding.”Agreed – but was this the nubof partnership working?“There is a real differencebetween partnership workingand collaboration,” said StephPalmerone, director of strategicinitiatives for Barchester. “A lotof people’s experience ofpartnership is coming to apartnership board meetingwhere everybody sits around atable but it is not part of theircore business. We are quite goodat making it work for individualsbut not so good at explainingwhy this is good for theorganisation and for the publicpurse.”This raised the issue of howformal partnerships should be.David Worskett, director of theNHS Confederation’s NHSPartners Network, said:“Partnership is a much overusedword. It is not justsubcontracting or a contractualrelationship. There is somethingin it about genuinely respectingand valuing each other.”He suggested the NHS andcare home sector might exploresome of the newer vehicles nowbeing tested in the NHS, such asjoint ventures. These had a goodtrack record in industry fromwhich the NHS could learn.Mr Flack agreed: “It feels tome, in a community interestcompany, we are now able to bemore innovative. We can thinkabout this in a different way.New ideas about joint venturesare much more alive to us as wecan do it quickly and begin toreap the benefits quickly too. Butit is still early days.”roundtablepanelStuart Bain, chief executive, EastKent Hospitals Foundation TrustRobert Flack, chief executive,Locala Community PartnershipsCommunity Interest CompanyRichard Hardman, director ofservice development, BarchesterHealthcareJeremy Hughes, chief executive,Alzheimer’s Society; chair, NationalVoicesProfessor Finbarr Martin, president,British Geriatrics SocietySteph Palmerone, director ofstrategic initiatives, BarchesterHealthcareMike Sobanja, outgoing chief officer,NHS Alliance (roundtable chair)David Walden, director of adultservices, Social Care Institute forExcellenceDavid Worskett, director, NHSPartners NetworkSuch formal arrangementscould lead to legal challenges,however. Mr Bain describedsome work done by his trust inpartnership with a localcommunity organisation onneurological rehabilitation.“We are now getting legalchallenges from othercommunity providers. Where isthe balance between a veryformalised approach throughjoint ventures and the lessformal?” he asked.Professor Finbarr Martin,president of the BritishGeriatrics Society and ageriatrician at Guy’s and StThomas’ Foundation Trust,said there was a dilemmabetween informal working that10 Health Service Journal supplement 14 June 2012 hsj.co.uk

Round table participants included (clockwisefrom left): Stuart Bain, Robert Flack, RichardHardman, Professor Finbarr Martin, StephPalmerone and Jeremy HughesIn association withallowed relationships, trust andknowledge to develop slowlyover time and more formalarrangements that specifiedgroups of patients, outcomecriteria and review as suggestedby Mr Bain.Setting boundaries“Informal working is a wayof reaching an operationalunderstanding but also a recipefor creating a morass ofmisunderstanding,” ProfessorMartin concluded. NHS and carehome staff needed to agree onthe objective, he said. For theNHS, the “job” was to findalternatives to acute admission.But this was not a responsibilitythe care home sector felt itshared – although it may benefitcommercially.On the flip side, he describedhow some joint work in his ownpatch to train care home staffhad been stymied by rigidfunding mechanisms.“Commissioners need jointlyto say it is their problem, butthey do not perceive it as theirproblem. I think partnershiprequires both parties to share theproblem,” said Professor Martin.Mr Bain agreed. “Both partiesneed to accept it is their problemand their opportunity and that itneeds to be their business,” hesaid. “Certainly the relationshipwe have with Barchester isabout what they can do betterthan us, and testing andevaluating that. That is aboutunderstanding which cohortsare better cared for in what wayand evaluating against criteria.People see themselves as part ofa team.”But who are the partners?Jeremy Hughes, chief executive‘Partnershipis not justsubcontracting– there issomething in itabout genuinelyrespecting andvaluing each other’of Alzheimer’s Society and chairof National Voices said allpartnerships must be at leastthree way and include serviceusers and carers. “Otherwise yourisk paternalism,” he said.David Walden, director ofadult services at the Social CareInstitute for Excellence, addedsocial care to the list. MeanwhileRichard Hardman, director ofservice development atBarchester, put in a bid forcommissioners. He describedwork with NHS CentralLancashire’s commissioningteam to develop innovative useof nursing homes to manageacute demand.“From a commissioning pointof view they have a very clearidea about the kind of servicesthey want,” he said. “They have adementia forum with users andcarers as members who help toshare ideas about what is bestfor the community. While thereis no formal structure to it, thereis a clear idea about what isrequired and we have adaptedour services around that and itworks well.”But the partnership withcommissioners was of a differentquality to that with providers,said Ms Palmerone. “It is almostas if commissioners perceivethemselves as the people in theposition to enable providers towork together or not,” she said.This was becoming moreapparent as personal social careand health budgets come moreinto play. “It almost feels likewILDE fryhsj.co.uk14 June 2012 Health Service Journal supplement 11

Clockwise from left (this page): Robert Flack,Steph Palmerone and Richard Hardman.Clockwise from top left (opposite): MikeSobanja, David Walden, Professor FinbarrMartin, Richard Hardman, David Worskettand Stuart Bainpersonal budgets are beingasked to glue the piecestogether,” said Ms Palmerone.The changing shape of theNHS, including the move both tosocial enterprise with its freedomto innovate and to the newclinical commissioning groups,presented a challenge, said MrBain. “These new organisationsare relatively immature and forpartnership to work, people needto be confident in their roles,” hesaid. “So we have an opportunityto unfreeze the system but also achallenge here.”Mr Walden pointed out thatcommissioners do not alwaysrepresent the entire populationwhen it comes to nursing homecare. In the south of England,some 80 per cent of nursinghome residents are self-fundedso the local authority and localNHS commissioners did not feelrelevant to them, he said. “Whatdoes partnership mean in thatcontext?” he asked. “Does itbecome more like a planningfunction?”Mr Hughes suggested this iswhere the forthcoming socialcare white paper may come intoplay – although any mention ofit was singularly absent from therecent Queen’s speech.“If you take an optimisticviewpoint, the social care whitepaper with its intention to focuson information provision for allrather than for recipients offunding may support this,” hesaid. It is also expected to havean emphasis on integration that‘For partnershipto work, peopleneed to beconfident intheir roles’could, in theory, support sharedrisk taking.Mr Bain argued that thecommissioner’s role inpartnership was fundamentallydifferent to the provider’s.Commissioners should bedeciding the what, andproviders in charge of the how.“[The] commissioner’s role isabout making sure people staywell,” he said. “They help themengage with their own illnesses,ensure that the right servicesexist for them if they need anintervention. It is not necessarilyabout telling all the providershow they should do that.”He argued that it was up toproviders to build care pathways.“It is of no benefit to myorganisation to have people inhospital who should not be thereor to be there for too long. Thisis about how we add positivevalue and that is best understoodby providers of care.”That was not to suggestproviders should not work withcommissioners, he added. “But Ifind commissioners are quitefrightened of that. They want totell you how to provide servicesand I do not think they are bestplaced to do that.” Rather, theyshould be defining excellenceand outcomes.There was general agreementabout this – although it shouldbe pointed out there was nocommissioner to argue the case.However, Mr Hardman said anorganic approach was needed. Itwas no good developing aservice if commissioners thenwon’t buy it, he pointed out.“It is about getting partnerstogether with innovative ideasalong with the commissioners.Commissioners will say theywill commission the service ifit has the features they knoware needed. They set theparameters.”The consensus view aroundthe table, though, was that mostNHS commissioners are notinterested in the care homesector. Quest for Quality, a recentreport from the British GeriatricsSociety, highlighted howgeriatrics expertise andprimary care services had beenwithdrawn from older people astheir long term care has shiftedfrom the NHS to the care homesector.Professor Martin said: “I donot see any strong evidencearound that primary care trustshave regarded the quality of careexperienced by individuals astheir problem. I do not have anyconfidence that that is going tochange quickly because I do notthink commissioning groupswill have the experience to do it.”He felt there was a role forconcerned geriatricians in theacute sector to make the case forbetter healthcare provision inthe care home sector and proveto commissioners there was awin-win to be had.A question of trustThere were also issues of trustbetween providers andcommissioners. Too often, saidMs Palmerone, commissionerswanted to repeat assessmentsalready carried out by providersand this led to a verybureaucratic approach thatbenefitted no one and stifledinnovation. The regulatoryregime was similarly poorlyequipped to support innovation,the participants agreed.Mr Hardman said: “As asociety we are so frightened thatsomething will go wrong so noone takes a risk and we are all12 Health Service Journal supplement 14 June 2012 hsj.co.uk

In association withlooking for the person who leftthe stable door open.”This left frail older patients inthe wrong place to meet theirneeds, said Mr Bain. “Certainlyfrom a provider perspectivethere is a default position whereeverything ends up in the mostexpensive, least flexible part ofthe service. Meanwhile, carehomes are becoming like miniinstitutions. There has to besomething more flexible thatworks around the needs ofpatients.”Mr Sobanja posed the killerquestion: “How do we breakthrough the set architectureand landscape? What is thestimulus for innovation andpersonalisation in a marketwhere providers are not shiftingthe system?”Several themes emerged fromthis including information andidea sharing, supporting patientchoice, improving customerservice, financial flexibility,using technology anddemonstrating efficiencies. Allthese would drive innovation inone way or another.For example, Ms Palmeronecalled for a “dating agency”.“Traditionally the NHS and notfor profit and for profit providersof care have not got together.That has tended to happen vialocal authorities and PCTs. Weneed a ‘dating agency’ wherepeople can explore together howthey can work together,” shesaid. This would perhaps be arole for the new national andregional commissioning bodies,she added.Mr Sobanja suggested thiswas perhaps an area where thenew health and wellbeingboards could bring theirinfluence to bear.Mr Hughes highlighted thework of the Dementia ActionAlliance, made up of over 100organisations committed totransforming the lives of peopleliving with dementia and thepeople caring for them. Eachhas signed a call to action,describing seven outcomes thatpatients and carers say wouldimprove their lives, and eachhas an action plan withspecific outcomes they wish toachieve by 2014. They includeorganisations as diverse as theRoyal College of Nursing, theNational Institute for Healthand Clinical Excellence andAlzheimer’s Society.Commissioners need to tapinto this alliance, he said. “Theyneed to be permissive ratherthan controlling.”Mr Bain addressed efficiency.“Efficiency is driven by lookingat how we add value to thepatient experience andoutcomes while saving money.When you are faced with thereality – 5-7 per cent savingsevery year – there is a verypowerful incentive to make sureyou are doing the right thing forpatients. That is the big driverfrom the acute side and I cannotimagine it is very different in thecare home sector.”This was all well and good intheory but the changes involvedas services shift are complex.The NHS had experience ofclosing mental healthinstitutions but, in many places,this was a slow process withadditional resources that allowedcommunity alternatives to buildup. This time, there is no money.“The money issue isabsolutely vital,” said MrHughes. Mr Walden agreed.“There is an opportunity toreshape rather than justcontract. But the danger is thatwe end up with the same stuffbut less of it.”Desired changeAt the end of this wide rangingdebate, Mr Sobanja set achallenge to the participants:name the one thing they wouldchange today.For Mr Bain this was clearlyfinancial – the need to alignhealth and social care budgets.“A more aligned system offunding would remove some ofthe discussion we have had tohave.” Mr Hughes’ ambition wassimilar: “To give health andwellbeing boards real powerover NHS and social careexpenditure.”Mr Flack and Ms Palmeroneboth wanted to introduce a carecoordinator for every personover 65. This would improvetheir customer care – somethingthe NHS gets badly wrong attimes – drive innovation andhelp them access the servicesthey need, when they need them.Professor Martin said hewould like people to “stopthinking that primary care willcome up with the solutionbecause I don’t think it will.”Mr Walden made a plea for“really good information andadvice provision for individuals,so, if they do have some choice,then it is a real choice and aninformed choice.”While Mr Worskett said hewants “to jump three years intothe future in terms of educatingand informing commissionersabout what is possible,” MrHardman was also ambitious:“I want to get away from theidea that a person centredapproach is an innovationand see a system where peoplefeel empowered when they arereceiving care.” lwILDE fryhsj.co.uk14 June 2012 Health Service Journal supplement 13

ADVERTISEMENT FEATURELeading Transformation whilst in TurnaroundIn September 2011 Monitor placedBurton Hospitals NHS FoundationTrust into financial turnaround.Whilst immediately instigatinga turnaround programme, theExecutive Team, led by HelenAshley, Chief Executive Officer,wanted more.“Delivering turnaround wascritical to our short term survival.However, we also knew that we hadto lead the organisation towards afuture vision and a better operatingmodel. To achieve this we had toengage our clinical leaders andthe broader Health System on atransformation journey”.The Trust appointed CapgeminiConsulting to work alongside itto define and deliver a changeprogramme.Burton’s vision is to be the localhealthcare provider of choice, actingas the patient’s ‘conductor’ throughcommunity, secondary and tertiaryhealth systems. (See figure 1) Thiswill be achieved through a clinicallyled model and effective communitynetworks and partnerships. Inorder to do this, Burton needsto ensure it is delivering its ownPatient Satisfaction wouldyou recommend this service to arelative?Staff empowerment andconfidence in own serviceQuality and Safety 1AccessA&EOutpatientsDiagnosticsInpatientsLOS (Based on CHKS)Level 1 –Need toTransformAbsolutes. Must support thetrust and maybe loss leadersbut define local healthcare.Good communicationand clear patientpathwaysLevel 2 –Need toImprove1. Will use existing quality and safety metrics by exception to monitor that there is no reduction in performanceLevel 3 –GoodPatientsCommunity HospitalTrustCore ServicesInterfaceLevel 4 –Excellent7.5%

whistleblowing‘Staff feeling aneed to use formalwhistleblowingprocedures can be a signthat something has gonewrong in an organisation’culture shockTo blow the whistle without fearing the consequencesrequires more than a change in the law, says Alison MooreHealth secretary Andrew Lansley came intooffice promising protection and new rightsfor NHS whistleblowers. But two years onhave things changed – and do NHS stafffeel any happier about speaking out?The NHS Constitution has been amendedto include:l an expectation that staff should raiseconcerns at the earliest opportunity;l a pledge that NHS organisations shouldsupport staff when raising concerns byensuring the concerns are fully investigatedand there is someone independent, outsideof their team, to whom they can speak;l clarity around the existing legal right forstaff to raise concerns about safety,malpractice or other wrongdoing withoutsuffering any detriment.New guidance has been issued to NHSorganisations saying whistleblowing rightsshould be included in employmentcontracts. In addition, an NHSwhistleblowers’ hotline is now being run byMencap and also covers social care workers.But is that enough? Jon Restell, chiefexecutive of Managers in Partnership,welcomes the changes but points out theimportance of also having cultural changewithin organisations. Staff feeling a need touse formal whistleblowing procedures canbe a sign that something has gone wrong inan organisation, he says. It can indicate thatthey are unable to discuss concerns withcolleagues and managers and see themresolved, and so resort to formal processes.“Policies and procedures can support aculture but they can’t create it,” he says.Dean Royles, director of NHS Employers,agrees about the importance of culture. Butas well as being able to raise concerns, hebelieves it is key to feed back to someonewho has done so. Managers need to beactive in changing culture, he says.“It is a journey but I have not come acrossanyone who thinks we should not beencouraging people to safely andconfidentially highlight issues of concern,”he adds.Desire versus dutyPublic Concern at Work believes things haveimproved in the NHS but there is still a longway to go. Francesca West, policy director,points to the increasing role of the CareQuality Commission in hearing from staffwith concerns as one example ofimprovement practice. And organisationsare now more likely to have awhistleblowing policy with pockets ofexcellent practice. Brighton and SussexUniversity Hospitals has a patient safetyombudsman whom staff can approach.But while many NHS organisations nowhave whistleblowing policies, there may stillbe a culture that prevents people speakingout, says Ms West. The role of managers –likely to be whistleblowers’ first port of call– is important here, she says. How they dealwith a whistleblower will affect whetherother people want to raise issues.She is also sceptical about the growingemphasis by professional regulators on aduty to speak out. This may ignore theclinician’s working environment, she says,and could lead to people being disciplinedfor not raising concerns despite thecircumstances. “It feels like we are puttingpeople between a rock and a hard place.”Kim Holt, a paediatrician whowhistleblew over what she saw as unsafepractices, says trusts are often defensive andfind it difficult to be open about mistakes.She is involved with Patients First, which isregularly contacted by health professionalswith concerns about their organisations.“There are some very high profile hospitalswhere things are not good,” she says. Manypeople just want their organisations to learnfrom their mistakes. This is also an issue formanagers she points out, saying: “There arevarious chief executives who won’t work inthe NHS again.”So what does the future hold? TheDepartment of Health is consideringwhether there is a need for more action.“Together with the national regulators, weare looking at how whistleblowing concernsare currently handled and, whereappropriate, implementing improvementsto systems for ensuring concerns are notoverlooked,” it says.But Mr Restell says financial pressures inthe NHS may create additional tensions astough decisions are made, which will impacton services. Having the right culture arounddecision making and raising concerns aboutthe impact of those decisions will beimportant; engagement and communicationwill be key to avoid defensiveness andadversarial relationships in which clinicianscould claim their concerns are beingoverlooked. Kim Holt believes boards coulddo more to question their executive teams.NHS Employers is planning to work withother organisations to look atwhistleblowing and the associated issues.But many people are holding their breath tosee what comes of the final Mid StaffordshireInquiry report – unlikely to appear beforeautumn. This could lead to much tighterregulation of managers and increasedemphasis on supporting whistleblowers. lalamyhsj.co.uk 14 June 2012 Health Service Journal supplement 15

ADVERTISEMENT FEATUREWe’re on the same teamThe NHS and local government must share commongoals to meet their community’s health and care needs.Collective leadership and strong relationships arerequired to make this happen says John WilderspinOver the course of the last year, oneof the issues which has constantlybeen at the forefront of our mindshas been ‘integration’. People havedifferent perspectives on what itmight mean, but everyone agrees thatit is important. However, as is oftenthe case with worthy aspirations,delivering the goal is much harder thansimply agreeing that it is important.To be fair, many bright andcommitted people have spent timethinking through how we best defineintegration, how we mightmeasure whether it ishappening, and how wecreate the pre-conditionsto allow it to flourish. Onthis latter point, there is anemerging consensus thatit can only really happen iforganisations work togetheracross their local system.In practice, this meansthat organisations need toshare a set of common goals,and empower their staff towork together around theinterests of the individualpatient or user.As with any changeprocess, this also requiresstrong leadership, butcollective leadership, not justleadership of individual organisationswithin the system. This is much harderand requires different leadershipskills and behaviours. It also requiresa broader perspective than we havetraditionally taken within the NHS.Most of us appreciate that integratedcare is going to require us to workwith colleagues in social care, whetherfor adults or for children and youngpeople. However, as our success startsto be measured in terms of outcomes,we are increasingly realising that thesystem we must work in is much biggerthan just the NHS and social care.But this ‘whole system’ thinking isby no means universal, and the NHStransition process has had an impacteven in those places where a ‘wholesystem’ approach was embedded.This is largely because good systemleadership relies on a shared senseof purpose and strong relationships,and transition has often resulted in achange of leaders, particularly on theNHS commissioning side.Fortunately, the advent of healthand wellbeing boards means that“It is really important thatthese integrated health andwellbeing boards deliverfor the people who reallymatter – the populationswe serve. By working inan integrated way we canmake a real differenceto the lives of ordinarypeople across the country.Everyone has a part toplay – whether leaders,clinicians or politicians. Itis up to all of us involved tomake them a success.”Professor Mike Cooke CBE, Chief Executive ofNottinghamshire Healthcare NHS Trust on NottinghamshireCounty Health and Wellbeing BoardCCGs, the new leaders of NHScommissioning, are already starting toform productive relationships withintheir local system. Shadow boardshave been up and running for severalmonths, and CCGs are getting used toworking with elected politicians andsenior officers from local government,as well as with their directors of publichealth. Crucially, they are also workingwith representatives of service usersand the local public, recognising thattrue system leadership has to havepublic engagement at its core. LocalHealthwatch – running from April 2013– will be the champion for people usinglocal services and will help ensure thatthese views and perspectives are fedin at every stage of the commissioningprocess.Health and wellbeing boards arealso thinking through what it meansto be the ‘system leader’ in this muchbroader system. Local government isused to influencing a wide range ofpartners to get things done for localpeople; ‘leadership of place’ is their corerole. But delivering integrated care andimproving health outcomes in a trulyintegrated way will requireco-leadership betweenlocal government and theNHS, which creates somesubstantial challenges.By definition, localgovernment is locallyfocused; the NHS has tobalance national and localpriorities to a much largerextent. The NHS is alsomade up of a number ofpowerful stakeholders andtheir active commitment isrequired if real integration isto become the norm. Activelyengaging providers, andother key NHS stakeholders,whilst ensuring that theNHS is not completelydominant, will be a key test of thematurity of a local system.John Wilderspin is the Department ofHealth’s National Director for Healthand Wellbeing Board Implementation.Visit us on stand C15 to find out moreabout the work underway to supportshadow boards to succeed in theirstatutory role from April 2013.Join the online community for theNational Learning Network forhealth and wellbeing boards athttp://knowledgehub.local.gov.uk/

age problemenvironment and our industry. And I thinkbecause they are a smaller company they arevery proactive in terms of support, even justin the procurement process. We were veryimpressed with how they dealt withperforming the install and, moreimportantly, the after support has beengood. You can get straight to supportbecause of the size of the organisation.”‘If patients understoodthat doctors have accessto their data quickly andit is secured safely, theywould feel reassured’The London cLinicIt is four years since Mike Roberts, ITdirector at The London Clinic, decided theHarley Street hospital could better manageits vast quantities of data. It was a decisioninfluenced in large part by his background.“I’m from consulting and have worked forIBM and PwC,” he explains, “so coming intothis sector was an interesting change.Looking at banking and mobile phones andutilities and all these other big commercialorganisations, I believe there’s a lothealthcare can learn about data architectureand management. I wanted to try to moveour architecture towards that commoncommercial way of working.”One of his main aims was to addressincreasing problems with backing up data.“Our previous backup architecture wasbased around the sort of standard Microsoftway of backing up,” he explains. “But wehave a large number of physiological devicesall with data on them that all need backingup. So we had this myriad of backup jobsand backup servers all taking copies of thedata, and trying to manage and organisethose was becoming really difficult. We hadsome backups taking 23 hours and that’sclearly not where you want to be.”Such problems were addressed by the2008 introduction of a solution fromBridgeHead Software. The product hascreated a single data store for all clinical andadministrative data and, significantly,limited the amount of data that is backed upby identifying what can, in fact, be archived.“Data ages very easily and there’s a lot ofdata duplication,” explains Mr Roberts. “Weneeded to find a way of getting rid of thatduplication and getting rid of the data thathas aged, but still have it available to usersbecause there’s always somebody who’sgoing to say: ‘Oooh, I wanted to look at MrsSo and So’s records from five years ago.’”The new system allows for just that and,although the data may be archived into adifferent place, Mr Roberts says thedifferences for users are minimal. “From thespace because of the size of people’s inboxes,”recalls Mr Brown. “So this solution allowedus to continue with that migration becausewe archived about half a million emails.”The result is that storage space was freedup – “we’re saving a massive amount ofspace within our email system,” says MrBrown – storage costs lessened, and now thecomputer systems run much faster for themany hundreds of staff who use email on adaily basis. All are allowed 12 months’ worthof emails within their own mail store witharchived messages retained for seven years.Mr Brown says he is delighted with theprogress that has been made and that it has,to a large extent, been made possible by thestrength of the relationship with theorganisation’s private sector partner.“Because BridgeHead specialises inhealthcare, they are well placed tounderstand our data, our hospitalend user’s point of view, they don’t reallynotice. Data might take a couple of secondslonger to turn up but they’re unaware ofthat, it’s transparent at their level.”For the IT team, however, the benefits areclear – lower overheads, not being tied in tospecific vendors, and cost savings from beingable to reduce the amount of disc storagespace that is needed. “Anything that reducesthe storage requirements, particularly forexpensive storage area network [disc spacewithin a network], is going to make my life alot easier,” explains Mr Roberts. But that isnot to say the project has been completelyfree of challenges. By his own admission, MrRoberts has stopped and started it “a numberof times” to confront issues that have beenthrown up by the process.“The sort of thing that has beenproblematic from my point of view is tryingto get the data into a fit state to actually bearchived,” he says. “As you take this journey,you unearth other issues that you perhapsmight have known were there but you werejust living with, or you hadn’t a clue werethere. There’s lots and lots of bits of thewider service delivery jigsaw puzzle thatstart to come at you.”Mr Roberts is confident that confrontingthese challenges has led to better care, even ifthe benefits aren’t – and he says they shouldnot be – immediately visible to patients.“We have long term relationships withsome of our patients, because they know andlove us, or they’re local, or unfortunatelysome people have conditions that requirehospital visits over a lengthy period.“So the knowledge that we are able toensure our doctors have access to that dataquickly and that it is secured safely inmultiple places – I think if they understoodthat, they would feel happy and reassured.But I’d be rather uncomfortable if there wasa wow factor: it should facilitate the patientexperience rather than being in their face,because it’s the clinicians using the data.” lcredit STylehsj.co.uk 14 June 2012 Health Service Journal supplement 21

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