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Collection Highlights

Key Topics in Management of the Critically Ill 1st Edition

Marcela P. Vizcaychipi

GROSS ANATOMY : the big picture. 2nd Edition Morton.

Big Data Analytics for Intelligent Healthcare Management

1st Edition Nilanjan Dey

Performance Management in Healthcare: From Key Performance

Indicators to Balanced Scorecard (HIMSS Book Series) 2nd
Edition Bergeron
The Big Picture Physiology - Medical Course And Step 1
Review 1st Edition Jonathan D. Kibble

Understanding Programming Languages 1st Edition Cliff B.

Jones

The Big Picture: Gross Anatomy, Medical Course & Step 1

Review David A. Morton

Understanding healthcare economics managing your career in

an evolving healthcare system Second Edition. Edition
William T. O'Donohue

Core Topics in Airway Management Cambridge Medicine Tim

Cook
Allied Health Professions – Essential Guides

Key Topics in Healthcare

Management
Understanding the big picture

Edited by
Robert Jones
and
Fiona Jenkins

Series Foreword by
Penny Humphris

Foreword by
Professor Gerry McSorley

Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business
First published 2007 by Radcliffe Publishing

Published 2016 by CRC Press

Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2007 Robert Jones and Fiona Jenkins

CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works

ISBN-13: 978-1-85775-708-8 (pbk)

Robert Jones and Fiona Jenkins have asserted their right under the Copyright,
Designs and Patents Act 1998 to be identified as the authors of this work.

This book contains information obtained from authentic and highly regarded sources. While
all reasonable efforts have been made to publish reliable data and information, neither the
author[s] nor the publisher can accept any legal responsibility or liability for any errors or
omissions that may be made. The publishers wish to make clear that any views or opinions
expressed in this book by individual editors, authors or contributors are personal to them and
do not necessarily reflect the views/opinions of the publishers. The information or guidance
contained in this book is intended for use by medical, scientific or health-care professionals
and is provided strictly as a supplement to the medical or other professional’s own judgement,
their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the
appropriate best practice guidelines. Because of the rapid advances in medical science, any
information or advice on dosages, procedures or diagnoses should be independently verified.
The reader is strongly urged to consult the relevant national drug formulary and the drug
companies’ and device or material manufacturers’ printed instructions, and their websites,
before administering or utilizing any of the drugs, devices or materials mentioned in this book.
This book does not indicate whether a particular treatment is appropriate or suitable for a
particular individual. Ultimately it is the sole responsibility of the medical professional to make
his or her own professional judgements, so as to advise and treat patients appropriately. The
authors and publishers have also attempted to trace the copyright holders of all material
reproduced in this publication and apologize to copyright holders if permission to publish in
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Except as permitted under U.S. Copyright Law, no part of this book may be reprinted,
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British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.
Typeset by Phoenix Photosetting, Chatham, Kent
Contents

List of figures ix
List of tables x
List of boxes xi
Series foreword xii
Foreword xiii
Preface xiv
About the editors xvi
List of contributors xvii
List of abbreviations xix
List of books in this series xxi

1 Public policy reforms and the National Health Service strategic

development agenda 1
Patricia Oakley
Introduction 1
A dynamic Public Policy Reform agenda 1
The context for developing AHP services in the 21st century 1
The structure of this chapter 2
The public service reform agenda 3
Developing commissioning and providing 3
‘Choice’ and patient power 3
Developing the market 4
Developing service commissioning and accountability 5
Strengthening financial governance and accountability 5
NHS commissioning and accountability across the UK 5
Developing commissioning in England 7
Developing service providers 9
Strategic development objectives of the policy 9
Developing a plurality of providers 10
Developing care outside hospitals 11
Developing multi-agency clinical networks 12
Developing a network of emergency and unplanned care
services 13
Developing a multiplicity of hospitals 15
Developing the workforce 16
‘Good Doctors, Safer Patients’ – the regulations of doctors 16
Fitness to practice – medical staff 16
The regulation of the non-medical healthcare professions 17
Knowledge management and its developments 18
The management agenda for AHPs 19
References 20
Further reading 21
iv Contents

2 Managing Change: a Framework for the Management of Change 22

Robert Jones and Fiona Jenkins
Introduction 22
Change 22
Key concepts 24
Culture 26
Leadership 26
Teams 28
Models, techniques and approaches for change management 28
Communicating change 35
Change leadership 36
How to overcome ‘change fatigue’ 36
Critical mistakes and errors 37
Key factors in effective change management 38
Key behaviours and success factors 39
Framework for the Management of Change 40
Case study 1 ‘Choice appointments’ 42
Moving from the current to the desired situation 42
Essential actions 43
Skills for success 44
Evaluation 45
Learning points 47
Conclusions 49
Case study 2 Stroke service re-design 49
Moving from the current to the desired situation 49
Essential actions 50
Skills for success 51
Evaluation 52
Learning points 52
Sustainable progress 53
Conclusion – change management 53
References 55

3 Care pathways and the Allied Health Professional 57

Fiona Jenkins and Robert Jones
The link between AHPs and care pathways 57
What is a care pathway? 58
The history and spread of care pathways 59
Why develop care pathways? 60
What care pathways contain 61
Care pathways and clinical governance 61
The aim of care pathways 61
Ten phases to developing care pathways 63
Phase 1: Choosing a clinical area 63
Phase 2: Review the evidence 65
Phase 3: Collect data and measure 65
Phase 4: Review current practice including process mapping 67
Phase 5: Identify key indicators 68
 Contents v

Phase 6: Drafting the care pathway 69

Phase 7: Review and revise ICP draft 71
Phase 8: Develop user version of care pathway 72
Phase 9: Launching care pathways 74
Phase 10: Monitor indicators – review and amend 76
Conclusion 79
References 80
Further reading 81

4 Communication and the health professional 82

Anne Mandy and Gail Louw
Introduction 82
What is communication? 82
Non-verbal communication 82
Clinical communication 83
Organisational communication 84
Communication competence 85
Team communication 86
Communication at different levels 88
Concept of behavioural style 89
Interactive dimensions 89
Four basic behavioural styles 90
Strengths and weaknesses of each style 91
Styles within teams and organisations 92
Communication styles of each category 92
Electronic communication and healthcare management 93
E-mail communication 94
Blogs 95
Wikis 95
Conclusion 95
References 95

5 Managing staff and Human Resources 98

Helen Anderson
Introduction 98
What is the state of the psychological contract today? 100
Team working 102
Investors in people 106
Plan 107
Do 108
Review 109
Conclusion 110
References 111

6 Getting it right: the quality of care 112

Alan Gillies
What is quality? 112
Definitions from within healthcare 114
vi Contents

Quality is a multidimensional construct 115

Conflicts and constraints 121
Clinical audit 122
Clinical governance 125
Providing the best possible care 127
Preventing harm 129
Who is responsible for quality? 130
References 130

7 User involvement in services for disabled people 132

Sally French and John Swain
The development of user involvement 132
Methods of user involvement 135
Barriers to user participation 136
Conclusion 140
References 143

8 Corporate governance and the health professional 146

Tove Steen Sørensen-Bentham
Governance 146
Absence of good governance 150
Clinical governance 151
Governance in joint working across the public services 154
Accountability 157
Governance for the future public services 159
References 160
Annexe: Corporate governance – questions and answers 161
Robert Jones and Fiona Jenkins

9 Organisational behaviour: understanding people in healthcare

organisations 164
Sharon Mickan and Rosalie A Boyce
Introduction 164
Healthcare organisations 165
Historical development of organisational behavioural theories 166
Impact on healthcare managers 170
A comprehensive theoretical framework 171
AHP structures 174
Practical perspectives 174
The transition to managing people 175
Perspectives on managing people 175
Perspectives on change 176
Perspectives on teamwork 177
Conclusion 177
References 178
 Contents vii

10 Managing health and safety in the workplace 180

Claire Sullivan
Introduction 180
Health and safety in the health services 180
Health and safety law in the UK 181
Background to the Health and Safety at Work Act 181
The HSC, HSE and enforcing the law 181
Understanding what the law means 182
Employers’ legal duties 183
Duties under HASAWA 183
Duties under other regulations 184
The ‘six-pack’ 184
The management of health and safety at work regulations and
workplace risk assessment 184
The manual handling operations regulations 1992/1999 187
The workplace (health, safety and welfare) regulations 1992 187
Display screen equipment 188
The personal protective equipment regulations 1992 188
Work equipment 188
The control of substances hazardous to health regulations 1999 188
The working time regulations 1998 189
The Reporting of Injuries, Diseases and Dangerous Occurrences
regulations (RIDDOR) 1995 189
Managing health and safety in practice 190
Health and safety responsibilities of AHP managers 190
Working with safety representatives 191
Workplace inspections 192
Safety committees 193
Common health and safety hazards and problems 193
Pregnant staff 194
Musculoskeletal disorders 194
Work-related stress 196
Bullying at work 196
Violence and aggression and lone working 196
Other health and safety hazards 197
Managing sickness absence and return to work 198
Managing health and safety successfully 199
‘Standards for Better Health’ and health and safety 199
NHS litigation authority risk management standards for Trusts 199
Further guidance from the HSE 199
Conclusion 202
References 203
Further information 204
viii Contents

11 Managing work-related stress 205

Laura McDonnell
Introduction 205
Introduction to the management standards 206
What is stress? 206
How did the management standards come about? 207
Existing health and safety law 208
How do the management standards help? 208
Sickness absence management 208
So what are the management standards? 209
How can the management standards help the risk assessment
process? 211
Overview of the process 211
Before using the management standards 212
Implementing the management standards 214
Step 1: Understanding the management standards 214
Step 2: Gathering information 214
Step 3: Exploring problems and developing solutions 217
Step 4: Action planning 219
Step 5: Monitor and review the effectiveness of interventions 220
Will the HSE enforce the management standards? 221
Are other approaches acceptable? 221
What is HSE doing to promote use of the standards? 222
Case study: application of the HSE management standards at
Hinchingbrooke Healthcare NHS Trust 222
Background 222
Why a stress management initiative? 223
The 2004 diagnostic survey 223
The ‘valuing staff’ campaign 226
Outcomes – the results for Hinchingbrooke 228
Cost benefit 229
Evaluation of the initiative 229
Conclusion 230
References 230
Further reading 231

Index 233
List of figures

1.1 Market forces providing pressure for providers 7

1.2 Developing commissioning and performance management and
reforming the Primary Care Trusts in England 8
1.3 Developing a plurality of providers – the component services 12
1.4 The emergency care network 14
1.5 The intensivist care network 15
1.6 The ‘hospital’ network for local communities 15
1.7 The knowledge management framework 18
2.1 Learning dip and sigmoid curve 24
2.2 A hierarchy of leadership 27
2.3 An overview of change management tools, models and approaches 29
2.4 Reactions to change 31
2.5 Iceberg process 32
2.6 Force field analysis 32
2.7 PDSA cycle 33
2.8 SWOT analysis 34
2.9 PEST analysis 35
2.10 Percentage DNA 46
2.11 Routine waiting time 47
2.12 Waiting time complaints 47
2.13 Was the information provided by the physiotherapy service
appointment system clear? 48
2.14 Would any other information have been useful? 48
3.1 Integrated care pathways and clinical governance 62
3.2 Plan Do Study Act cycle 67
3.3 An example of an ICP algorithm for Parkinson’s disease 69
3.4 An example of an algorithm for back pain 70
3.5 An example of patient produced information 72
3.6 Patient version of care pathway 73
3.7 A care pathway continuous cycle of improvement 77
4.1 The strengths and weaknesses of each behavioural style 91
5.1 The three principles of IIP standards 106
6.1 Visual analogy of quality as a multidimensional construct 115
6.2 Garvin’s model: five views of quality 117
6.3 A view-based model of the quality of patient care 120
6.4 There may be conflicts between different views 122
6.5 The clinical audit cycle 123
7.1 Ladder of user involvement 135
11.1 Overview of the management standards process 212
11.2 Example of the screen display generated by the analysis tool 216
List of tables

1.1 NHS commissioning 6

1.2 Changes in commissioning processes 6
1.3 The clinical knowledge management programme 18
2.1 Seven phases to social change intervention 30
2.2 Change leadership 37
2.3 Leading change – why transformation efforts fail 37
2.4 Change management factors 38
2.5 Key behaviours and success factors 40
3.1 Checklist for pathway maintenance 76
4.1 Characteristics of organisational communication 84
4.2 Communication styles, limitations and most preferred electronic
communication style 93
5.1 Model of team effectiveness 103
6.1 Summary of Garvin’s views of quality 118
6.2 Auditing cycle for AHPs 129
9.1 Competing values framework 173
11.1 Survey results for Hinchingbrooke Healthcare NHS Trust 225
List of boxes

1.1 Key issues for doctors’ revalidation 16

1.2 A watch list for AHP managers 19
2.1 Processes for development 30
2.2 8-Stage process of change 30
2.3 Communication strategy 36
2.4 Framework for the management of change 41
2.5 Reactions to change 54
3.1 NPA definition of a care pathway 59
3.2 The aims of care pathways 61
3.3 Ten steps to developing care pathways 63
3.4 Project team members and skills 64
3.5 Types of key indicators 68
3.6 Items for consideration when developing ICP documentation 71
3.7 Benefits and barriers to care pathway implementation 78
4.1 Categories of behavioural style 90
5.1 Requirements of an employer of choice 101
5.2 Team leadership tasks 104
5.3 Key elements to promote effective team working 105
6.1 HPC standards of proficiency 127
6.2 NHS staff survey 2005 – AHP findings 130
7.1 Key principles for informing user involvement with disabled people 141
7.2 User involvement checklist 141
8.1 The seven principles of public life 148
8.2 Main responsibilites of CHAI 153
8.3 Partnership working questions 158
10.1 Risk assessment documentation requirements 186
10.2 Workplace regulations (1992) topics 187
10.3 Working time regulations – key points 189
10.4 Items to be included in organisational health and safety policies 190
10.5 Managers’ health and safety responsibilities 191
10.6 Key rights of health and safety representatives 192
10.7 Case studies 195
10.8 The 4 Cs for a positive health and safety culture 200
11.1 Management standards: demands 209
11.2 Management standards: control 209
11.3 Management standards: support 210
11.4 Management standards: relationships 210
11.5 Management standards: role 210
11.6 Management standards: change 211
11.7 User views 214
11.8 Key learning points from users 216
11.9 What users said about focus groups 218
11.10 Some examples of questions for focus groups 219
11.11 Further comments from users 220
11.12 Some final comments from users 222
Series foreword

The NHS, the biggest organisation in the UK and reputedly the third largest in the
world, is undergoing massive transformation. We know that effective leadership
is essential if the health service is to achieve continuous improvement in the
services it offers. It needs people from all types of backgrounds – clinical and
managerial – to step up and take on leadership roles to shape the future of health
improvement and healthcare delivery.
Leaders are needed at every level of the health service. The concept of
leadership only coming from the top and being defined by position and title is
now out of date. It is much more about ways of thinking and behaving and
individuals seeing themselves as having the potential to make a real difference for
patients. Effective leadership is about working in partnerships and teams to
develop a vision for the future, set the direction, influence those whose input is
needed and deliver results – a high quality, safe, timely and accessible health
service for all.
Allied health professionals operate in every setting in which healthcare is
delivered. You have unparalleled opportunities to help patients to lead their own
care and to see how services to patients, clients and carers can be improved across
entire patient pathways, crossing traditional professional and organisational
boundaries to improve patients’ experiences. You have the potential to make a
difference by leading improvement and managing services and resources well.
There are already many outstanding leaders in the NHS in the allied health
professions making a real difference to services. Two of them had the vision for
this series of books and have worked with formidable energy and commitment to
make them a reality. Robert and Fiona have both made a considerable investment
in their own professional and personal development and delivered substantial
improvements in the services for which they are responsible. They have increased
their awareness, skills and knowledge and taken on leadership roles, putting into
practice many of their ideas and learning. They have worked tirelessly to spread
their learning and skilfully persuaded a great many academics and practitioners
to contribute to these books to provide a rich collection of theories, tools,
techniques and insights to help you.
This series of books has been written to encourage and support many more of
you to embark on or to continue your development, to enhance your leadership
and management skills, knowledge and experience and to give you confidence to
take on new roles and responsibilities. I am sure that many of you, who have not
previously considered yourselves as leaders will, when you have read these
books, reconsider your roles and potential and take the next steps on your
journeys.

Penny Humphris CBE

Former Director, NHS Leadership Centre
August 2007
Foreword

Capturing in writing the essence of good leadership and management is no small

task. So much of what we observe, experience, share and witness of our actions
and others’ can be difficult to translate into text. As Levinson, a writer on
leadership said some ten years ago ‘Leadership is like beauty; it’s hard to define,
but you know it when you see it!’ It is here that Rob Jones and Fiona Jenkins
make such a mark. By compiling a series of experts who have translated the
contemporary leadership, management and policy challenges into an excellent
body of work to aid those committed to improving the standards of care to
patients through their good management practice. Their collective efforts make
for a journey of understanding and knowledge of great value to the reader in
terms of the task of managing within the complex policy framework the NHS
operates in today.
This complexity of policy and management is unlikely to become simpler with
time. All agree that the shifting sands of politics, public and staff expectations will
not, and arguably should not, stand still as we hope for better services. The
movement to expansive careers and changing roles highlights the enormous
contribution that Allied Health Professionals (AHPs) have to help drive forward
the many improvements we all wish for. The need for continuing professional
development is essential if this contribution is to be made to the full. Seizing the
precious opportunity for critical thinking and reflection in otherwise busy lives
will be greatly aided by the writing contained here.
The NHS is not short of space for great talent to come forward in small or large
ways and AHPs continue to offer a unique clinical viewpoint on how we enrich
the way we design and deliver healthcare. It is through our shared understanding
of the climate we work in and the techniques of good management and self-
reflection that drive on our vocation, that our hopes and aspirations for progress
will be gained.
Jaworski highlights the key attribute of leadership (either in us or in others) as
about creating the domain in which we continually learn and become more
capable of participating in our unfolding future. He argues that we must shift from
seeing the world as clockwork, fixed and machinelike, to one which is open,
dynamic and interconnected, and full of living qualities. Once we see this shift we
move from resignation to a sense of possibility. We are then able to create the
future every moment.
Jones and Jenkins, along with their co-writers, provide such a sense of
possibility and therefore an impressive step to a better future.

Gerry McSorley
Honorary President, Institute of Healthcare Management
August 2007
Preface

There are many challenges and opportunities for healthcare managers; the NHS
reform agenda and the multi-layered strategy for service improvement is
extensive and complex. AHPs are well placed to make significant and positive
contributions to the provision of effective and efficient, patient-centred and
responsive services. The many challenges and opportunities should be used to
stimulate action, thought, reflective practice and innovation in service provision
and we hope that the scope, spectrum and depth of chapters in this book will be
supportive.
There are many publications available on all aspects of management theory and
practice. However, to date there has not been a specific book focusing on the key
‘Big Picture’ topics as they relate in particular to the Allied Health Professions.
With so many fundamental and radical changes and upheavals taking place at
such a rapid pace in the NHS and health services worldwide, we believe that this
is the right time for this book to set out and expand on the broad context of
change and development in healthcare management, leadership and
development.
Our series ‘Allied Health Professions – Essential Guides’, of which this is the
third book, is intended for AHP managers and aspiring managers, leaders,
clinicians, researchers, educators, students and non-AHP Registrants within the
remit of the Health Professions Council. The series is also useful for doctors,
nurses, pharmacists, optometrists, other professionals working in healthcare
management and leadership roles and general managers.
This volume focuses on the context of structural, organisational and
management changes within the NHS and wider health and social care
environments, encompassing theory and practice, policy developments,
innovations and new or different ways of working. The areas explored and
discussed relate to the NHS and wider healthcare provision in the 21st century.
The perspective is wide ranging focusing on important broad vision issues which
are all parts of the overall picture and about which – we believe – managers and
leaders need an understanding in order to work effectively and succeed.
All of the contributors to this volume, Key Topics in Healthcare Management –
understanding the big picture, have recognised expertise nationally and
internationally and are widely experienced in their fields. The text is not a
continuous narrative, but a collection of subjects closely related and linked into
the whole to provide a comprehensive view of the context, content and relevance
of issues which overarch many areas; all topics relevant to the development,
provision and maintenance of ‘best quality’ services for patients, clients and
service users. We have not attempted to significantly adjust the style of individual
authors, although each chapter stands in its own right, there are major themes
which bring the different aspects together.
We would like to thank all of our contributors for sharing their knowledge,
experience and expertise, it was a great privilege to work in close collaboration
 Preface xv

and harmony with them all. We would also like to thank our publisher, Radcliffe
Publishing Ltd for their support, encouragement and expertise.
AHPs must be proactive and responsive to the many changes taking place,
whenever and wherever possible, to see the upheavals as opportunities,
transforming them into positive steps towards the improvement of our services.
There is no ‘best, right or only one way’ of management and leadership; our aim,
and that of all our contributors, is to set out approaches and provide an in-depth
and wide range of information which we believe will enhance the evidence-base,
knowledge, understanding and skills to support managers, leaders and clinicians
to manage and lead their services pro-actively, effectively and efficiently and by
so doing, provide the best quality service possible for our patients and service
users.

Robert Jones and Fiona Jenkins

August 2007
www.jjconsulting.org.uk
About the editors

Dr Robert Jones PhD, M.Phil, BA, FCSP, Grad Dip Phys, MHSM, MMACP
Head of Therapy Services, East Sussex Hospitals NHS Trust.

Robert has management responsibility for therapy services in one of the largest
trusts in the country. He manages a large team of therapy and support staff in
acute services, primary care, external contracts and the independent sector.
A Physiotherapist by background, he is the former Physiotherapy Registrant
Member of the HPC and a former Chair and Vice President of the Chartered
Society of Physiotherapy.
Robert was seconded to the Commission for Health Improvement for a year as
AHP consultant/advisor, he represented AHPs on the NHS Information Authority
Project Board and QAA steering group. He lectures both nationally and
internationally on management topics, IM&T in Allied Health Professions and
service improvement and design. His PhD is in management and his M.Phil is in
Social Policy, he has published widely on management and clinical topics.

Fiona Jenkins MA (dist.), FCSP, Grad Dip Phys, MHSM, NEBS Dip(M), PGCO
Non-medical Clinical Director of Therapy Services, South Devon Healthcare
Foundation Trust.

Fiona manages a physiotherapy service in a large acute trust with services also
provided in primary care. A former Council member and Vice President of the
Chartered Society of Physiotherapy, Fiona has led a large number of service
improvements across South Devon which have received national recognition. She
lectures both nationally and internationally on management topics. Her MA is in
management, and she is currently further undertaking research for a PhD.

Fiona and Robert successfully completed the INSEAD NHS/Leadership Centre

Clinical Strategists’ programme at the business school in Fontainebleau Paris and
continue to undertake project work with the university. They were
Modernisation Agency Associates and have worked collaboratively on service
improvements, developments and innovation. They have established a
consultancy, which provides management workshops, masterclasses, lectures and
presentations on healthcare management topics nationally and internationally:
www.jjconsulting.org.uk.
List of contributors

Helen Anderson BA, FCIPD

Human Resources Consultant, London

Professor Rosalie A Boyce PhD, Mbus, BSc, Grad Dip Dietetic,

Grad Dip Health Admin
School of Pharmacy, University of Queensland
Visiting Professor, Sheffield Hallam University

Dr Sally French PhD, MSc (Psych), MSc (Soc), BSc, Dip TP, MCSP
Associate Lecturer Open University

Professor Alan Gillies PhD, MA, MILT, MUKCHIP, Doctor Honoris Causa
Professor in Information Management
University of Central Lancashire

Dr Gail Louw PhD, MA, MSc, BA

Principal Lecturer
Institute of Postgraduate Medicine
Brighton and Sussex Medical School

Laura McDonnell BSc (Hons)

Stress Programme Team
HSE
Health and Work Division
London

Dr Anne Mandy PhD, MSc, BSc (Hons), Cert Ed

Research Student Division Leader
Principal Research Fellow
Clinical Research Centre
University of Brighton

Dr Sharon Mickan PhD, MA, BOT (Aust), Cert Ed

Consultant Researcher, University of Queensland
Mickan Consulting, Frankfurt and Brisbane

Dr Patricia Oakley PhD (Organisational Psychology), MBA (London),

BSc (Pharmacy), Grad IPD, MRPharmS, DHMSA
Director, Practices Made Perfect Ltd
London
www.practices.co.uk
xviii List of contributors

Tove Steen Sørensen-Bentham MSc, Llm

Principal Lecturer
Brighton Business School, University of Brighton

Claire Sullivan MA, MCSP, Grad Dip Phys

Assistant Director of Employment Relations and Union Services
Chartered Society of Physiotherapy
London

Professor John Swain PhD, MSc, BSc, PGCE

Professor of Disability and Inclusion
University of Northumbria
List of abbreviations

A&E Accident and Emergency

ACAS Advisory, Conciliation and Arbitration Service
ACEVO Association of Chief Executives of Voluntary Organisations
ACOP Approved Codes of Practice
AfC Agenda for Change
AHP Allied Health Profession
AHPs Allied Health Profession(s)
BDA British Dietetic Association
BIOS British Orthoptic Society
BMA British Medical Association
BPR Business Process re-engineering
CEO Chief Executive Officer
CHAI Commission for Healthcare Audit and Inspection
CHI Commission for Health Improvement
CMO Chief Medical Officer
CNST Clinical Negligence Scheme for Trusts
COT College of Occupational Therapists
COSHH Control of Substances Hazardous to Health
CPD Continuing Professional Development
CSP Chartered Society of Physiotherapy
CT Computer Tomography
DDA Disability Discrimination Act
DET Disability Equality Training
DH Department of Health
DoH Department of Health
DHSS Department of Health and Social Security
DNA Did Not Attend
DSE Display Screen Equipment
E-mail Electronic Mail
EPP Expert Patient Programme
EU European Union
EWTD European Working Time Directive
GMC General Medical Council
GMS General Medical Services
GP General Practitioner
HASAWA Health and Safety at Work Act
HMSO Her Majesty’s Stationery Office
HPC Health Professions Council
HR Human Resources
HRM Human Resource Management
HSC Health and Safety Commission
HSE Health and Safety Executive
xx List of abbreviations

ICP Integrated care pathway

IIP Investors in People
IM&T Information Management and Technology
ISO International Standards Organisation
IT Information Technology
IWL Improving Working Lives
KSF Knowledge and Skills Framework
NHS National Health Service
NHSLA National Health Service Litigation Authority
NHSNI National Health Service Northern Ireland
NICE National Institute for Health and Clinical Excellence
NMC Nursing and Midwifery Council
NPA National Pathways Association
NRLS National Reporting and Learning System
NSF National Service Framework
OECD Organisation for Economic Co-operation and Development
PBC Practice Based Commissioning
PbR Payment by Results
PCRN Primary Care Research Network
PCT Primary Care Trust
PDSA Plan Do Study Act
PEST Political Economic Social and Technological
PMETB Post Graduate Medical Education and Training Board
PPI Patient and Public Involvement
QOF Quality Outcomes Framework
RCSLT Royal College of Speech and Language Therapist
SCP Society of Chiropodists and Podiatrists
SFI Standing Financial Instructions
SHA Strategic Health Authority
SMART Specific Measurable Achievable Realistic Timed
SNDMSG Send Message
SOR Society of Radiographers
SS Social Services
SWOT Strengths, Weaknesses, Opportunities, Threats
RIDDOR Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations
TIA Transient Ischaemic Attack
TQM Total Quality Management
TUC Trades Union Congress
UK United Kingdom
USA United States of America
VDU Visual Display Unit
www World Wide Web
List of books in this series

Managing and Leading in the Allied Health Professions

Developing the Allied Health Professional
Key Topics in Healthcare Management: understanding the big picture
Managing Money, Measurement and Marketing (provisional title)
Understanding Staff Management (provisional title)
Managing the Health Professional (provisional title)
Chapter 1

Public policy reforms and the National

Health Service strategic development
agenda
Patricia Oakley

Introduction
A dynamic Public Policy Reform agenda
As an illustration of the dynamic situation; at the time of writing, for instance, the
Government is working on complex legislation and major proposals to:
• reform the way in which medical and professional staff are going to be
reaccredited and validated in the future during all of their working lives
• develop public service commissioning in the NHS, the secondary education
service, and the prison and probation services, which will have a bearing on
how therapy services will be developed in the future
• build up the intriguingly titled ‘3rd sector’ as a supplementary provider of
public services which will affect future models of care provision.
Within this changing environment, the aim of this chapter is to pinpoint the key
policy areas which are now fairly stable features of the Public Policy Reform
Agenda so that Allied Health Professions (AHPs) Managers can start to see more
clearly how their AHP services will be commissioned, provided, and quality
assured in the future. To this end, this chapter represents a synthesis of much
research which has been augmented by the Author’s practice in many streams of
policy and development work across the public sector. Parts of this chapter have
appeared in earlier forms in various working papers, policy masterclasses and
their supporting notes, and service evaluation reports for clients especially over
the last five years.

The context for developing AHP services in the 21st century

There are at least five important forces which are driving the development of AHP
services in the 21st century:
1 the changing population profile and people’s needs as they live longer in a
more independent way while being increasingly sensitive to the tax burden
2 Key Topics in Healthcare Management

2 the desire to achieve a more ‘joined-up’ approach to public service policy-

making, service commissioning and its provision, with the desired collective
effect of achieving ‘improved outcomes’
3 the desire to achieve a more locally accountable government structure in the
form of devolution to the Regional Assembly Governments in Wales, Scotland,
Northern Ireland and London, and possibly – in time – to the other English
regions
4 the changing legal context being driven by shifts in European law, for example
in employment practices and the free movement of labour across member
states, and in clinical practices and the conduct of safer and more rigorous
clinical trials
5 The changing risk management environment as a result of major inquiries and
legal rulings clarifying and assigning duties and responsibilities.
Taking the first point to locate this introductory discussion in AHP services, within
the last ten years, there have been several major reports on people’s changing
needs for health and social care including:
• the Report of the Royal Commission on Long Term Care, 19991
• the Audit Commission’s series of reports2,3,4,5,6 covering health and social care
provision, 1997–2000
• the Department of Health (DH) proposals to improve chronic disease
management.7,8
These reports, and many others, have explained why, and informed how, AHP
services should be delivered in a more integrated way focusing on chronic disease
management with an emphasis on self-care and the provision of intermediate
care. The comparative review by Ham et al9 of hospital bed utilisation in the NHS
with the US Kaiser Permanente and Medicare Programmes in 2003 gives an initial
analysis of the data to support this proposition.
The other driving forces will be discussed in the relevant sections below.

The structure of this chapter

This chapter also discusses Government policies in a hierarchical analysis which
covers:
• an overview of the Public Service Reform Agenda to show the common ideas
emerging across the public service so the NHS reforms can be located in the
wider policy context
• an overview of the NHS commissioning reforms including the development of
the more aggregated primary care trusts (PCTs) in England and their
equivalents in the devolved administrations
• an overview of the NHS provider organisations including the social enterprises
and voluntary sector which make up the ‘3rd sector’ and the changing
regulatory structure which affects the workforce.
The chapter concludes with an assessment of the potential collective impact of
these reforms on developing AHP services in the 21st century and it offers AHP
managers a ‘watch list’ of key issues which they will need to address in order to
reform their services.
 Public policy reforms and the National Health Service strategic development agenda 3

The public service reform agenda

Developing commissioning and providing
The public service reform agenda emphasises the separation of service
commissioning from its provision. For example, in social services, which have
operated this policy for many years, the White Paper for England,10 sought to
further integrate health and social care provision, and to develop more integrated
service commissioning for care of the elderly and for those with long-term
conditions. Similarly, the Government’s proposed reform of the provision of
secondary schools in England will result in the Local Education Authorities
becoming in time, commissioners of secondary education and secondary schools
developing in a more independent and plural way driven by local demands.11
The Government also proposes a major reform of its prison and probation
services (for England and Wales) following the Carter Review.12 This in effect
follows the pattern above but requires new and complex legal powers to develop
‘Correctional Services’ commissioning, through a new body called the National
Offender Management Service, and a more integrated prison and probation
service which focuses on providing prisoners with bespoke rehabilitation and
treatment programmes so that their resettlement in the community is likely to be
more successful. Currently, up to 60% of discharged prisoners reoffend and
return to prison within one to two years of their discharge date. Critically, much
of the rehabilitation and treatment programmes required consist of education and
skills building supported by mental health and detoxification treatment
programmes.
In addition, in respect of the ‘Lifers’ and those detained indefinitely in the
specialist psychiatric prisons, the Government proposes a programme of support
as these prisoners become old and infirm, and suffer from the normal process of
ageing including senile dementia. Because the reform programme is so complex
and sensitive, it will take a number of years to implement but clearly there are
overlaps between the programme commissioners for correctional services and the
emerging commissioning roles for the education, health and social services.13,14

‘Choice’ and patient power

The ‘choice’ agenda reflects in part the shifting public attitudes to public service
provision, especially in England. This is illustrated by two contrasting populations
of mature and elderly women. On the one hand, is a group of women born after
World War Two – the ‘baby boomers’ who are relatively more educated,
especially as a result of the education reforms that took effect in the mid to late
1960s and who have had jobs resulting in pension contributions and savings over
a long working life. This group forms the next generation of women pensioners
who are in effect ‘healthier, stealthier and wealthier’. They have different
attitudes to public service provision which they have contributed to for all their
working lives and they tend to be well-informed ‘consumers’.
In contrast, there is a group of women pensioners who have experienced the
horrors and deprivations of life before and during the Second World War and who
saw the birth of the NHS and its universal ‘free’ service. They tend to be less
‘muscular’ in asserting their rights. With an emphasis on looking after themselves
4 Key Topics in Healthcare Management

and their family, mature and elderly women form the backbone of the UK carer
‘workforce’, and they are critical to the well-being of not just themselves but also
of their families. In policy terms, the Government needs to satisfy both groups to
prevent a two-tier service emerging. For brevity, this is a gross simplification of the
social group mixes as the story is indeed much more complex. However, this brief
explanation underpins, in part, the Government’s proposals to develop under the
aegis of the White Paper, the ‘Expert Patient’ Programme, focusing on Long Term
Conditions such as diabetes, mental health, cardiac problems.8 In addition, there
are about four million people in the UK in receipt of disability benefits. The
Government seeks to mobilise a proportion of these people back into the
workplace under the ‘Pathways to Work’ scheme.15 As a result, they will require
support for their Long Term Conditions, particularly mental health problems.16
With the growth in the proportion of the elderly in the UK, and the
commensurate pressure on the tax-funded health and social care service, and an
increasingly tax-averse public, the policy bundle described above needs to be
supported by an expanded service and therefore more resources. The proposals to
bring health and social care closer together opens the public debate about funding
a future joint service and the issue of whether the Government should allow more
direct and co-payments which are used in social services to support the directly
funded service from the taxpayer. This is a major policy issue for the next general
election.

Developing the market

The Government has developed a number of policy instruments to underpin the
proposed market system which will operate in England. Two central developments
are the framework of rules to make the market work which is known as the
contestability process, and the introduction of foundation NHS trusts. As NHS
trusts meet the strict financial performance criteria, they are granted such status
which in effect loosens them up from some central control making them a little
more independent, but accountable to the public service commissioner.
To support the market, the Government is developing a set of tables which state
the ‘programme of care and its tariff’. At the moment, it covers England only,
mainly in surgical procedures but there are plans to bring out similar tables for
programmes covering long-term conditions and mental health services in
2006–09. Once the glitches have been resolved, and the proposed contract
currencies are validated, this will allow the market to operate from about
2008–09. It is complicated work and it is estimated that it will take 10–15 years
to bed down in the NHS (based on experiences in the US and Germany).
To develop the market in England, the Government needs to protect the taxpayer
and patients. To this end, it has set up a Market Regulator – known in the NHS as
Monitor – which has powers of entry to foundation trusts if they deviate from their
financial tolerance levels when it can issue painful course correction notices. The
Government has also set up an inspectorate known as the Health Commissioner
who has power of entry to the whole service on a rolling basis of inspection when
it can issue improvement notices and recommendations for change. The
Government also needs a Contract Compliance Officer who can ensure the
performance of the contracts issued by the Service Commissioner. This office is
likely to be located in the new – Regional – Strategic Health Authorities (SHAs) (see
 Public policy reforms and the National Health Service strategic development agenda 5

discussion below). In practice, these roles have some degree of overlap and
following a review, the Government will clarify their future domains of authority.

Developing service commissioning and accountability

Strengthening financial governance and accountability
The Government raises taxes from the British public and allocates the resources
against the many claims on the fund after Parliament has approved the Government’s
budget. Part of this fund is then allocated to the Scottish Parliament, Welsh Assembly
Government and the Northern Ireland Office and their First Ministers, elected
members and lead officers decide how much of their fund will be spent on the NHS
within their jurisdiction. In England, the fund for the NHS is allocated to the DH which
then administers it through the SHAs.
As it is public money, it has to be accounted for to Parliament where the
Comptroller and Auditor General reports on the value for money achieved and
the efficiency of the public service. Similar arrangements apply in the devolved
administrations. As a result of this strong financial governance framework, the
NHS has to publicly allocate, and account for, its resources according to the rules
laid out in the Standing Financial Orders, Standing Financial Instructions and the
Scheme of Reservations and Delegations.17
Two important developments will affect how the financial governance and
reporting framework will operate in the NHS in the future:
1 the Enron disaster and the Higgs Commission – as a result of the Enron
financial disaster and subsequent inquiries in the US, the UK Government (via
HM Treasury and the Department for Trade and Industry) commissioned a
review of the likelihood that such a disaster could happen in the UK. The
resulting Higgs Report has highlighted potential weaknesses particularly in the
way Boards work in their scrutiny role and has made recommendations to
strengthen this area. These recommendations inform how public bodies need
to strengthen their financial governance arrangements18
2 the Arm’s Length Bodies Review – to ensure that the bulk of taxpayers money
is spent on public services rather than on an infrastructure of bureaucracy, the
Government has started a review of all the Arm’s Length Bodies with a view
to reducing their numbers and size, and to streamlining the costs of
administering public services. As a result, many inspection and advisory bodies,
and public funding bodies, are being merged, or disbanded, and their running
costs severely capped.19
This set of developments creates the context within which the NHS
commissioning system will develop over the next three to five years.

NHS commissioning and accountability across the UK

A recent review of the effectiveness of primary care led commissioning and its
place in the NHS from the Health Foundation has shown that from 1991–1997,
commissioning policy was largely consistent across the four countries of the UK.
Since 1997 however, the approach has varied, and the authors20 have summarised
this in Table 1.1.
6 Key Topics in Healthcare Management

Table 1.1 NHS commissioning.

England the purchaser-provider split has been largely retained and PCTs
have become the main local commissioning body and they are
charged with developing new forms of devolved practice-led
commissioning
Northern Ireland local health and social groups have been created as a method of
developing effective clinical and public engagement in the
commissioning process. The groups have however struggled to
secure GP involvement
Scotland the quasi-market was abolished and the funding system was
returned to the directly managed – central allocation system where
commissioning and providing roles are effectively integrated.
Community Health Partnerships are viewed as key forums for
determining local health and social care priorities and plans
Wales the purchaser-provider split has been retained with a strong
emphasis on forming local partnerships with local Government
and local communities focused on 22 Local Health Boards

Table 1.2 Changes in commissioning processes.

England the number of SHAs and PCTs has been dramatically reduced and
their respective roles and responsibilities are being redefined to
focus them on developing more effective service commissioning
and accountability. As a result, PCTs now cover larger
geographical areas and they are supported by a number of
administrative back up services which are organised at a regional
level to achieve economies of scale savings. PCTs have a specific
duty to develop GP practice-based commissioning and they will
lose, in time, their service provider duties
Northern Ireland the number of Health and Social Service Boards and their
constituent Health and Social Care trusts has been dramatically
reduced so that there is now one Board for Northern Ireland
which will commission and work with five super health and social
care provider organisations. It is unclear how GP involvement will
be taken forward
Scotland the number of Health Boards and their functions are under
review and the development of service commissioning and
performance management within the context of the local
Community Health Partnerships depends on how the Scottish
Parliament wants to develop its governance and accountability
structures and processes, including involving GPs
Wales the number of Local Health Boards, working with their local
authority partners, is under review but many have already
developed shared commissioning duties and responsibilities across
three regional networks which are also supported by a national
commissioning group
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