Item 7

BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST

BOARD OF DIRECTORS TO BE HELD ON WEDNESDAY 29 AUGUST 2012

CHIEF EXECUTIVE’S REPORT ACTION: This is the CEO’s briefing of current and emerging issues and our responses to those to date. The Board of Directors are required to digest this information; seek points of clarification and debate the direction of travel that this contextual briefing will have upon our future plans and decision making as a Board.

1. National Policy/Changes

Sir David Nicholson (CEO, NHS Commissioning Board Authority and Chair of the National Quality Board) has issued a report outlining how ‘quality’ will operate within the new NHS architecture. The main messages in the report are as follows:

• Quality is systemic. It is not the responsibility of any one part of the system; it is the collective endeavour, requiring collective effort and collaboration at every level of the system. • Clarity and understanding is required concerning the distinct roles and responsibilities for quality across the system. • Frontline professionals (both clinical and managerial) who deal directly with patients and carers are critical. • Boards and senior leaders of healthcare are ultimately responsible and accountable for ensuring the quality of care delivered is high, and for when things go wrong. • Commissioners are responsible for the quality of care they commission and regulators should perform their statutory functions with the best interests of patients at heart. • To strengthen the new system the report sets out a new network of local and regional Quality Surveillance Groups (QSG’s). QSG’s will bring together commissioners, regulators and other parts of the system to share information and intelligence about quality in order to spot the early signs of problems and to take corrective and supportive action to prevent early problems becoming more serious quality failures. These will be supported and facilitated by the NHS Commissioning Board and will be operational in each local area by April 2013. • The National Quality Board’s report can be found at www.dh.gov.uk/health/2012/08/quality-new/. I suggest this is received in depth during one of our forthcoming Board seminar sessions and then taken forward through our Quality and Safety Committee.

2. Transitional Changes and National Arrangements

In preparation for the changes across commissioning arrangements as part of the Health and Social Care Bill, the following transitional arrangements will come into effect from the 1 October 2012:

• Birmingham and Solihull PCT Cluster and the Black Country PCT Cluster will cease their operational duties on 30 September 2012. The Birmingham, Solihull and Black Country operating arm of the National Commissioning Board will be established in ‘shadow’ form from 1 October 2012.

Page 1 of 3 • PCT Clusters will retain their statutory and governance functions until April 2013. To ensure stability and resilience over the coming six months through transition, regional Directors of the NHS Commissioning Board will assume operational delivery and responsibility for planning 2013/14.

3. No Health Without Mental Health

The implementation framework for the national mental health strategy – ‘no health without mental health’ has been published. A summary is included at Attachment 1. Directors are working to ensure that the contents feed into our own service planning arrangements and indeed into discussions with current and emergent Commissioners.

4. Care Quality Commission

The CQC have undertaken several visits over recent weeks; Meadowcroft (July), Eden PICU (July), Trust wide systems for safeguarding (August 2012) and Juniper Centre (August 2012). Final reports for Meadowcroft and Eden PICU have been published and confirm that the CQC have found the services to be compliant. The draft report for Trust wide safeguarding systems has been received for comments and again finds the Trust to be compliant. The final report will be published in September. The report for Juniper is part of a wider national review of services for older people which focuses upon dignity and nutrition. Feedback on the day of the visit was positive, but the report may take longer to issue since it is part of a national review.

Once the report concerning Trust wide safeguarding systems is published, Monitor will review our governance ratings which are currently assessed as amber-red. With full compliance having been reported from each of the visits this should restore our Monitor rating to either amber-green, or green. The outcome should be known in time for our AGM in September.

5. Monitor Key Targets

The Board will be aware that the Trust was unable to declare compliance with the newly introduced target for ‘% of CPA reviews conducted within the past 12 months’ at Quarter 1. I am pleased to report that the required 95% compliance was achieved as at 21 August 2012. Providing this performance continues to be sustained (or improved further) this will result in a positive declaration for Quarter 2.

6. Service Changes: Patient Safety

Newbridge House acute inpatient units cater for both men and women. Although technically compliant with DH requirements it has remained a source of some unease for the Board that both men and women who are acutely unwell are cared for within the same unit. Following two recent incidents at Newbridge House, I have used my temporary closure/service change powers as Accounting Officer of the Trust to move swiftly towards the conversion of Newbridge House into a single gender unit. We will of course seek a presentation to the Health Overview and Scrutiny Committee at the earliest opportunity. The changes result in Newbridge House becoming an all-female unit serving Birmingham North and East, with Eden acute (Northcroft) becoming an all-male unit serving Birmingham North and East. Commissioners are aware and supportive.

Solihull acute wards continue with the same constraints as Newbridge has had.

Page 2 of 3 Options are being actively discussed with Commissioners in Solihull but since this may require the utilisation of Birmingham based facilities for Solihull residents, agreement may be more difficult to reach. The situation will be kept under close review balancing both ease of access with patient safety

Sue Turner Chief Executive August 2012

Page 3 of 3 briefing July 2012 Issue 247

No Health Without Mental Health: implementation framework

Key points In February 2011 the Government published No Health Without Mental Health, its cross-government, all-age strategy for mental health in • In February 2011 the England.1 The NHS Confederation’s Mental Health Network (MHN), on Government published No behalf of its members, was heavily involved in the development of the Health Without Mental Health, strategy. We welcomed the vision it set out to improve outcomes for its strategy for mental health in England. mental health service users and promote positive mental health and wellbeing amongst the whole population. Delivering the improvements • The strategy set out six objectives the strategy aims for will be a key test of the Government’s wider reform for improving mental health and programme. wellbeing. • The Mental Health Network The implementation framework has been developed jointly by the has been working with the Department of Health, the MHN, Mind, Rethink Mental Illness, Turning Department of Health and Point and the Centre for Mental Health. The framework has three other partners to develop an central aims. Firstly, it sets out how progress will be monitored through implementation framework for outcomes, and how the range of outcome measures currently available the strategy. will be built upon in future. Secondly, and most importantly, it makes a series of recommendations for local and regional organisations to take • The implementation framework forward. Thirdly, it details a series of national commitments to support recommends evidence-based implementation. actions for the NHS, other public services and employers. This Briefing provides an overview of the framework, focusing on those • The framework details how areas that are most relevant to providers of NHS mental health services. success will be measured and how future work on outcomes indicators will be taken forward Background be taken forward. For the nationally. Department of Health, important Changes set out in the Health levers to help drive improvement and Social Care Act marked out include the mandate to the NHS new parameters within which Commissioning Board and the new implementation of No Health NHS, public health and adult social Without Mental Health could care outcomes frameworks. briefing 190247 TheNo Health CRC Energy Without Efficiency Mental Scheme Health: andimplementation the NHS: what framework you need to know and do

For the NHS, the role of the NHS ‘We expect our organisations to be judged by the contributions Commissioning Board in driving they make to realising this framework’s ambition’ forward implementation will be Joint foreword to the implementation framework by Sir David critical, particularly as the Board Nicholson (NHS Chief Executive and Chief Executive Designate, comes to consider how it will NHS Commissioning Board) and Duncan Selbie (Chief Executive construct the Commissioning Designate, Public Health England) Outcomes Framework, and in its role as a commissioner of NHS services. The Board’s endorsement of the framework is therefore Health will publish a national user engagement, pointing to particularly welcome. Similarly, mental health dashboard this initiatives such as Star Wards.4 with changes to public health autumn. Measures currently being The importance of establishing services currently underway, the considered are set out in the table protocols for sharing information endorsement of Public Health on page 3. with carers is highlighted, including England is valuable. working with primary care to Recommendations for determine how best to act on In common with the original information regarding potential the NHS 5 strategy, the implementation crisis. framework is wide ranging Providers of mental health services in scope and makes The implementation framework For safety, the importance of recommendations for a wide recommends that mental health strengthening clinical practice, range of public services beyond services focus on improving risk management and continuity the NHS. These include schools, equality, in terms of access to of care are all crucial. Manchester local government, social services services and outcomes from care. University’s Twelve points to a safer 6 and the criminal justice system. Providers may want to consider service is a valuable tool. how they currently measure Measuring outcomes service activity and outcomes Innovative use of information has aggregated by Equality Act the power to transform mental The implementation framework characteristics. Providers can also health services. There is real sets out how work on a national extend this to other vulnerable potential for mental health services mental health dashboard will be groups known to experience to make better use of technology, in taken forward. The NHS, public particular mental health providing self care and peer support health and adult social care problems, such as homeless online. outcomes frameworks all currently people and people from certain contain measures with specific Black and Minority Ethnic (BME) The importance of orientating relevance to mental health. communities. services around recovery is However, there are significant important. Services need to provide gaps in terms of measurement – Improving experience for service support and access to appropriate most notably, outcomes related users and carers is key. The advice on housing, benefits and to recovery and indicators relating framework recommends that debt issues. Providers will also to children and young people. providers ensure they implement want to consider how they deliver Furthermore, measures contained NICE’s quality standard on evidence-based employment within the various outcomes service user experience in adult support, training and education. frameworks (and other national mental health2 and the You’re The Implementing Recovery datasets) are collected and Welcome standards for young Through Organisational Change published in different places. people.3 Providers will also want (ImROC) programme, run by the to consider how they record and MHN and the Centre for Mental The mental health dashboard will monitor patient reported outcome Health, is a source of advice and map the most relevant measures measures and how this supports good practice in this area.7 Enabling from the three outcomes continuous service improvement. choice of treatment and medication frameworks, and elsewhere, based on available evidence, and against the objectives of the Related to the above, the enabling service users to exercise strategy. The Department of framework focuses on service choice in care planning (including

02 briefing 247 No Health Without Mental Health: implementation framework

Measures being considered for the first mental health dashboard 1. More people have better mental 2. More people will recover 3. Better physical health health • Self-reported wellbeing (PHOF) • Employment of people with • Excess under-75 mortality rate in mental illness (NHSOF) adults with severe mental illness • Rate of access to NHS mental (NHSOF & PHOF, Placeholder) health services per 100,000 • People with mental illness population (MHMDS) or disability in settled accommodation (PHOF) • Number of detained patients (MHMDS) • The proportion of people who use services who have control over • Ethnicity of detained patients their daily life (ASCOF) (MHMDS) • IAPT recovery rate (IAPT • First-time entrants into youth Programme) justice system (PHOF)

• School readiness (PHOF)

• Emotional wellbeing of looked after children (PHOF, Placeholder)

• Child development at 2–2.5 years (PHOF, Placeholder)

• IAPT: access rate (IAPT Programme) 4. Positive experience of care and 5. Fewer people suffer avoidable 6. Fewer people experience stigma support harm and discrimination • Patient experience of community • Safety incidents reported • National Attitudes to Mental mental health services (NHSOF) (NHSOF) Health Survey (Time to Change)

• Overall satisfaction of people who • Safety incidents involving severe • Press cuttings and broadcast use services with their care and harm or death (NHSOF) media analysis of stigma (Time to support (ASCOF) Change) • Hospital admissions as a result of • The proportion of people who self harm (PHOF) • National Viewpoint Survey – use services who say that those discrimination experienced services have made them feel safe • Suicide (PHOF) by people with mental health and secure (ASCOF) • Absence without leave of problems (Time to Change) • Proportion of people feeling detained patients (MHMDS) supported to manage their condition (NHSOF) Key ASCOF – Adult Social Care Outcomes MHMDS – Mental Health Minimum • Indicator to be derived from a Framework Dataset children’s patient experience IAPT – Improving Access to NHSOF – NHS Outcomes Framework questionnaire (NHSOF, Psychological Therapies PHOF – Public Health Outcomes Framework Placeholder)

03 briefing 190247 TheNo Health CRC Energy Without Efficiency Mental Scheme Health: andimplementation the NHS: what framework you need to know and do

The implementation framework makes recommendations of their whole population and for the following organisations commissioning the right services for them, including for seldom- • Clinical commissioning groups • Health overview and scrutiny heard groups. This includes (CCGs) and primary care trust committees people not registered with a GP (PCT) clusters and those less likely to access • Local Healthwatch mainstream services, such as • Providers of mental health homeless people. services • Community groups The framework cites a number • Schools and colleges • Providers of acute and of sources of specialist support community health services • Employment support (Jobcentre and guidance for mental health Plus, work programme providers) commissioning, including • Primary care providers NICE quality standards and guidance produced by the Joint • Local authorities • Employers Commissioning Panel for Mental • Health and wellbeing boards • Criminal justice agencies Health. It also recommends drawing on specialist expertise, • Social services • Housing organisations including mental health networks where they are established. • Commissioners and providers of public health services A number of areas are specified where more effective commissioning could improve outcomes and experience, joint planning with service On stigma, providers can inspire a including improving transitions users, including crisis and safety culture where discrimination has and ensuring focus on early planning) are also highlighted. no place and stigma is actively challenged. Many providers have intervention is maintained. Improving the physical health already signed up to Time to and wellbeing of people with Change to show their commitment The framework stresses the need mental health problems is a key to tackling mental health stigma. for commissioning to support objective of No Health Without greater choice in mental health, including choice of treatment. Mental Health and is central to Commissioners of mental health The framework recommends that the implementation framework. services the full range of NICE-approved Initiatives can focus on smoking Improving the commissioning therapies are commissioned and cessation, weight management of mental health services will that service users have a greater and tackling drug and alcohol form a vital element of the choice of providers through the misuse. work of clinical commissioning groups (CCGs) and the NHS use of Any Qualified Provider. Mental health providers have Commissioning Board. developed innovative services Commissioners should aimed at improving the mental The framework recommends that commission innovative service health of people with long-term CCGs and primary care trust (PCT) models to help improve the physical conditions and medically clusters appoint a mental health mental health of people with unexplained symptoms. The lead at senior level. CCGs may also long-term physical conditions savings to the NHS that can be wish to establish a sub-committee and medically unexplained made through increased use of which includes mental health symptoms. Examples include liaison psychiatry services, talking professionals. liaison psychiatry services, therapies for people with long- talking therapies for people term conditions and services for Commissioners will want to with long-term conditions and people with medically unexplained assure themselves that they are services for people with medically symptoms, are all highlighted. assessing the mental health needs unexplained symptoms.

04 briefing 247 No Health Without Mental Health: implementation framework

Providers of acute and community The identification and treatment agencies). Overview and scrutiny health services of co-morbid physical and mental committees and local Healthwatch Services should ensure that clinical illness is of critical importance. both have an important scrutiny and other staff are able to spot the This includes providing targeted function. Healthwatch will want to signs of mental ill health. Ensuring mental health interventions for ensure that people who use mental staff in A&E services are equipped people with long-term physical health services, their families and to respond to mental health needs conditions (such as coronary heart carers, are recruited as part of their is particularly important. disease and diabetes) as well as membership. Local community action to improve the physical groups and user-led organisations Acute services are encouraged health of people with mental health can also play an important role to develop liaison psychiatry problems. feeding into needs assessments. services where they do not already exist. Services such as the RAID Primary care providers can consider Social services will want to (Rapid Assessment Interface and how to increase access for groups work alongside CCGs to remodel Discharge) service have been with known vulnerability to mental existing support to focus on early shown to save money for the NHS health problems and those who are intervention, service integration, by reducing hospital admissions under-represented in primary care personalisation and recovery. By and lengths of stay.8 At least £1 mental health services, including better joining up health, social in every £8 spent on long-term homeless people. Providers may care and housing support we can conditions is linked to poor mental also want to consider arranging improve mental health outcomes. health and wellbeing.9 A significant appropriate training for their Older people, either living in their proportion of this cost could be workforce in relation to mental own homes or in residential care, saved by better management of health. are especially vulnerable to mental the mental health of people with health problems. Social services Developing good practice in care have a critical role in ensuring the long-term conditions. Collaborative planning (including crisis care mental health needs of older people care arrangements outside hospital planning) for people with mental are identified and acted upon. can also improve people’s ability to health problems is also highlighted manage their own health and offer in the framework, including Children’s services will want to work a cost-effective way of joining up improving transitions between alongside CCGs, schools and wider mental and physical healthcare for primary and secondary care. children’s services to focus on early people with long-term conditions.10 intervention and integrated support. The importance of improving Services are also encouraged to Wider recommendations emotional support for children on support local work to prevent Reflecting the original scope the edge of care, looked after and suicide and manage self-harm. of No Health Without Mental adopted children is also highlighted. Health, the framework sets out Primary care providers recommendations for a broad range The framework recommends that The framework makes a number of organisations and public bodies. public health services develop of recommendations for primary a clear plan for public mental care providers. These include For health and wellbeing boards, health. This could incorporate the improving access to support the framework stresses the need three-tier approach to improving services, including peer support for robust Joint Strategic Needs public mental health: universal and befriending organisations. Assessment and ensuring mental interventions to build resilience Primary care providers can improve health needs are properly assessed. and promote wellbeing for all the identification of people at Boards may consider appointing a ages; targeted prevention and risk of developing mental health named board member as lead for early intervention for people at problems and provide appropriate mental health. Boards are ideally risk of mental health problems, for early interventions. Providers can placed to bring together local example older people living in social also ensure people with mental partnerships and encourage joint isolation; and early intervention with health problems are able to exercise commissioning between health and children, young people and families. choice – particularly in terms of health-related services (including Ensuring health improvement treatment options. criminal justice, drug and alcohol efforts consider the specific physical

05 briefing 190247 TheNo Health CRC Energy Without Efficiency Mental Scheme Health: andimplementation the NHS: what framework you need to know and do

‘The draft mandate recognises Prosecution Service can ensure they on mental health awareness the importance of putting are aware of the options available through a new e-learning package. mental health on a par with to enable treatment for offenders, physical health’ including the use of cautions with The National Diversion Programme conditions attached to attend an is to roll out liaison and diversion appointment with mental health services for mentally ill offenders health needs of people with mental services. Courts can also ensure by 2014. A liaison and diversion health problems can also help they are aware of the options network has been set up, currently deliver improved public health available to them, including to comprised of 94 adult and youth outcomes. divert offenders with mental health pathfinder sites, alongside up to problems from custody, where ten police forces. The MHN is part Good schools and colleges support appropriate. of the collaborative that will run the children and young people’s liaison and diversion network. wellbeing and understand the National support for link between mental health and implementation The NHS Commissioning Board educational outcomes. They The NHS Commissioning Board can provide access to targeted, Government support will be committed to improving evidence-based interventions for The mandate to the NHS outcomes in mental health and will children and young people who Commissioning Board will set out play a central role in supporting have, or are at risk of developing, the Government’s objectives for implementation of the strategy. emotional and behavioural the Board. A consultation on the Mental health will be one of eight problems, alongside universal first mandate, which will apply key commissioning areas that mental health promotion from April 2013 to March 2015, will be used as themes to assess approaches. Tackling bullying, which is currently underway. The draft applications for CCG authorisation. puts children and young people at mandate explicitly recognises the Applicant CCGs will need to significant risk of developing mental importance of putting mental show that they have sufficient health problems, is key. health on a par with physical health. planned capacity and capability to commission improved outcomes in In order to have the best chance of The Department of Health will mental health. recovery, it is important that people publish a suicide prevention with mental health difficulties are strategy later this year. The The NHS Commissioning Board sufficiently catered for within the forthcoming children and young will hold CCGs to account for the Work Programme, Work Choice people’s health outcomes strategy outcomes they achieve through and Access to Work schemes. will identify the health outcomes the Commissioning Outcomes Effective management of mental that matter most to children, Framework. The Board will publish health in the workplace can also young people and their families. In the final indicator set in autumn bring about significant savings for addition, the Office for Disability 2012. employers. The framework makes Issues is developing a new cross- a series of recommendations for government disability strategy. The NHS Commissioning Board employers around how to support The Government will support the commits to meet the objectives the mental health of employees in Parliamentary passage of the of the mandate as they relate to the workplace, including to consider Mental Health (Discrimination) (No. mental health. The Board will joining the Mindful Employer 2) Bill, which aims to repeal four ensure it receives high-quality scheme and signing up to the Time discriminatory pieces of legislation. advice in relation to mental to Change campaign. health. It is currently developing a Access to Work will be marketed mechanism to allow it to draw on No Health Without Mental Health so that under-represented groups, views and expertise from across emphasised the importance of such as those with mental health the mental health sector. It will ensuring offenders (including young problems, are better able to ensure that people who use mental offenders) have the same access participate. Teachers and others health services, their families and to mental health services as the working with children and young carers, can play a full role in its rest of the population. The Crown people will have access to training involvement work.

06 briefing 247 No Health Without Mental Health: implementation framework

Recommendations for housing commissioners and providers Mental Health Network Housing organisations can: viewpoint The Government’s reform • Help ensure housing is included in health needs assessments to inform programme has meant major commissioning plans. changes not only for the structure of the NHS, but also in terms of • Identify tenants with risk factors for mental ill health and ensure access how the NHS implements future to appropriate prevention and early intervention services. government policy. Delivering the improvements that No Health • Work with NHS organisations to provide integrated support for people Without Mental Health aims for will with mental health problems, so improving outcomes and reducing be a key test of the Government’s overall costs. wider reform programme.

• Ensure staff and contractors receive appropriate, evidence-based mental We hope the implementation health awareness training. framework is a useful starting point for commissioners and providers • Ensure debt and rent arrears collection processes are sensitive to people of NHS services, and other bodies, with a range of needs. in terms of deciding how best they can improve the mental health and wellbeing of their local populations. Public Health England Public Health England will support The commitment from the Public Health England will integrate work on suicide prevention, as one Department of Health to publish a mental health and wellbeing of the key public health challenges national mental health dashboard is throughout all of its key functions in improving mental health and a positive step and we look forward and approaches. In setting its wellbeing. to working with them closely on programme of work, Public Health this important piece of work. We England will consider how it will Other national commitments particularly welcome the support contribute to meet the mental The framework contains a series of and endorsement of the NHS health and wellbeing requirements commitments from the Care Quality Commissioning Board and Public of the Public Health Outcomes Commission, Monitor, the Royal Health England. Framework, and improve the College of Psychiatrists, the Royal collection and integration of data College of GPs, Health Education Developing the framework has been on wellbeing, mental health, mental England, the Royal Society for a positive example of co-production illness, suicide and self-harm. Public Public Health, the Faculty of Public between the Department of Health Health England will consider how Health and the National Institute and the mental health sector, which it will support local work to assess for Health and Clinical Excellence. we hope is replicated again in future. mental health and wellbeing needs. The framework also includes It will also consider how best to commitments from members of For more information on the issues build capacity and capability across the reference group who developed covered in this Briefing, contact the wider and specialist public the content of the implementation Rebecca Cotton at health workforce. framework, including the MHN. [email protected]

Implementation Framework Working Group The Implementation framework has been co-produced by the Centre for Mental Health, the Department of Health, the Mental Health Network, Mind, Rethink Mental Illness and Turning Point.

07 briefing 247 No Health Without Mental Health: implementation framework

References 1. HM Government (February 2011), No health without mental health: a cross-government mental health outcomes strategy for people of all ages.

2. National Institute for Health and Clinical Excellence (January 2012), Quality standard for service user experience in adult mental health. Available at: www.nice.org.uk/guidance/qualitystandards/service-user-experience-in-adult-mental- health/index.jsp

3. Department of Health (2007) You’re Welcome quality criteria: making health services young people friendly. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073586

4. More information about Star Wards can be found at: www.starwards.org.uk

5. Service Delivery and Organisation Programme (2006), Sharing mental health information with carers: pointers to good practice for service providers. Available at: www.netscc.ac.uk/hsdr/files/project/SDO_BP_08-1309-054_V01.pdf

6. More information about twelve points to a safer service can be found at: http://www.medicine.manchester.ac.uk/cmhr/centreforsuicideprevention/nci/saferservices

7. More information about the Implementing Recovery through Organisational Change (ImROC) programme can be found at www.nhsconfed.org/imroc

8. Mental Health Network (2011), With money in mind: the benefits of liaison psychiatry. Available at: www.nhsconfed.org/ Publications/briefings/Pages/With-money-in-mind.aspx

9. King’s Fund and Centre for Mental Health (February 2012), Long-term conditions and mental health: the cost of co- morbidities. Available at: www.centreformentalhealth.org.uk/pdfs/cost_of_comorbidities.pdf

10. Mental Health Network (April 2012), Investing in emotional and psychological wellbeing for patients with long term conditions. Available at: www.nhsconfed.org/Publications/reports/Pages/ InvestinginEmotionalandPsychologicalWellbeingLongTermPatients.aspx

Mental Health Network The NHS Confederation’s Mental Health Network (MHN) is the voice for mental health and learning disability service providers to the NHS in England. It represents providers from across the statutory, for-profit and voluntary sectors. The MHN works with government, NHS bodies, parliamentarians, opinion formers and the media to promote the views and interests of its members and to influence policy on their behalf.

Further copies or alternative formats can be requested from: Tel 0870 444 5841 Email [email protected] or visit www.nhsconfed.org/publications The NHS Confederation © The NHS Confederation 2012. You may copy or distribute this work, but you must 29 Bressenden Place London SW1E 5DD give the author credit, you may not use it for commercial purposes, and you may not Tel 020 7074 3200 Fax 0844 744 4319 alter, transform or build upon this work. Email [email protected] Registered Charity no: 1090329 www.nhsconfed.org BRI024701