2014 / 2015 HEALTHCARE EDITION

A YEAR IN PERSPECTIVE

 FOREWORDS The Rt Hon George Osborne MP The Rt Hon Jeremy Hunt MP

 REPRESENTATIVES NHS Tameside and Glossop East and North Hertfordshire Clinical Commissioning Group Clinical Commissioning Group Liverpool Heart and Chest Luton & Dunstable University Hospital NHS Foundation Trust Hospital Foundation Trust The Royal Marsden NHS Queen Victoria Hospital NHS Foundation Trust Foundation Trust Northamptonshire Healthcare Dartford and Gravesham NHS Trust NHS Foundation Trust Bolton NHS Foundation Trust

 FEATURES Review of the Year Review of Parliament

©2015 WESTMINSTER PUBLICATIONS www.theparliamentaryreview.co.uk

Foreword

The Rt Hon George Osborne MP Chancellor of the Exchequer

The UK grew faster than any other major advanced radical new apprenticeship levy on large firms. We’re economy in the world last year, and is set to do the also devolving even more powers to local areas over same again this year. Over the past 5 years we created things like planning, skills and Sunday trading rules. two million new jobs. And the deficit – now 3.7% of And to back British businesses and encourage them to GDP – is a third of what we inherited in 2010. invest we’re setting the annual investment allowance at £200,000 and cutting corporation tax to 18% by 2020 – But all that progress could be put at risk if we don’t making it the lowest in the G20. continue with the plan that is delivering for the working people of this country. The final part of the plan is to make sure work always pays, so at the Budget I announced a new national living Economic security is at the heart of that plan. It’s not wage, reforms to our welfare system and lower taxes for enough to simply eradicate the deficit – we have to working people so we move Britain to being the higher reduce our unsustainably high level of national debt. wage, lower tax, lower welfare economy we want it At the Budget I published a revised Fiscal Charter that to be. commits us to running a surplus in normal times to bear down on debt. In the autumn the House will vote on that charter and I hope it will mark the start of a new settlement for Britain’s public finances.

Improving productivity – the amount that British Improving productivity is workers produce for every hour they work – is the key route to making the UK stronger and families the key route to making richer, and it’s the greatest economic challenge of our “ the UK stronger“ and families time. We’ve set out concrete steps that we’re going to take to improve the infrastructure, education and skills richer, and it’s the greatest of the UK – and to make sure that this time it’s a truly economic challenge of national recovery. Some of the biggest reforms include setting up a new roads fund to pay for the sustained our time investment our roads so badly need and introducing a

FOREWORD | 1 Foreword

The Rt Hon Jeremy Hunt MP Secretary of State for Health

I was delighted and humbled to be reappointed Health We must ensure that the NHS becomes a truly 7-day Secretary following the general election in May. It is a service, where patients know they will receive the same great privilege to serve the hundreds of thousands of quality of care and treatment whether they fall ill on doctors, nurses and other NHS staff working incredibly a Tuesday or a Saturday. I am delighted that David hard to provide high-quality care, and the millions of Cameron used his first major speech after the general patients and families whose lives have been changed by election to announce plans to achieve this. their dedication and expertise. The NHS is facing serious challenges. We have an Over the past 5 years, we have achieved a lot. We ageing population, increasing consumer expectations, increased spending on the NHS in real terms every and growing numbers of people who are living year in the last Parliament and, as David Cameron has with long‑term health conditions such as dementia promised, we will do the same in this Parliament too. and diabetes. We know that the strength of the NHS depends on the strength of the economy, and our long-term plan will I am confident that with the increased investment we ensure the stability and growth on which the health have committed, the NHS’ own long-term plan that we service depends. are backing and, above all, the dedication and talent of frontline staff, we can rise to those challenges, and Today there are 9,400 more doctors and 7,700 more become the world’s safest, most compassionate and nurses than there were in 2010. Last year, the NHS best value health service.

carried out over a million more operations than 5 years ago, and saw over six million more outpatients. And

the service has embraced one of the biggest health challenges of our time, with more than 430,000 NHS staff undertaking dementia training to help them “ care for vulnerable patients. We must ensure that But there is more work to do. Over the next 5 years, the NHS becomes a truly we must transform out-of-hospital care so that older and vulnerable people get the joined-up support they “ 7-day service need at home and in their communities.

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Jeremy Hunt’s ‘reformation moment’

a system with the confidence to be honest about failings is a system that does something to put them right.’

Adapting a phrase from the science fiction and cyberpunk novelist William Gibson, Mr Hunt went on to say: ‘The future of the NHS is already here, it is just unevenly distributed’.

One eye-catching move announced in the King’s Fund speech was for Lastminute.com founder Martha Lane Fox to produce a report on how technology could shift power more easily to patients. The cross-bench peer will submit her proposals to the NHS The NHS is seeking National Information Board before the ‘intelligent transparency’ end of the year. Two months after his reappointment as health secretary in May, Jeremy Mr Hunt’s wide-ranging speech Hunt unveiled his ‘25-year vision’ for also saw an offer to senior NHS the NHS. The secretary of state made leadership that he would hold them major announcements on pay, staffing, to fewer targets in exchange for management culture and the structure greater transparency. Although one of the service during a speech at the waiting‑time target has already been King’s Fund think-tank in Cavendish relaxed, it is not yet clear which other Square, London. He also set out his targets the NHS will be allowed to vision to make the people who use cease reporting on. the English NHS ‘the most powerful patients in the world’. Mr Hunt reaffirmed some already trailed announcements, such as the Mr Hunt told delegates: ‘[former printing of the price of expensive Conservative minister] Nigel Lawson drugs on the packaging so patients famously described the NHS as a can see how much they cost. The national religion. The problem with move is part of a wider push to get the religions is that when you question public to take greater responsibility for the prevailing orthodoxy, you can end their own health. up facing the Spanish Inquisition. NHS orthodoxy was that criticism should The most eye-catching measure not be made public because it would announced was his support for ‘damage morale’. We now see that changing hospital doctors’ contracts was wrong. Intelligent transparency is so they could be required to work at becoming a ‘reformation moment’ for weekends. Quoting research about the NHS as the public appreciate that worse outcomes for patients admitted

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at weekends when fewer senior staff told to discontinue its work on safe are on duty, Mr Hunt directly attacked staffing levels by NHS England earlier the British Medical Association (BMA). in the year. NHS England, the national commissioning body for NHS services, In a question-and-answer session after said this was because the work would his speech, the health secretary was be rolled up in a larger programme asked by Labour MP for Islington South it was carrying out – although there and Finsbury Emily Thornberry whether was suspicion in some quarters that antagonising medics was a good way the intention was to try to check the to achieve the changes to the NHS he growing cost of staff in the NHS by desired. Mr Hunt replied that he had avoiding an official and binding staff/ yet to meet a doctor who opposed patient ratio. the principles of 7-day working, and that the BMA was out of touch with The secretary of state reversed its members. NHS England’s position, saying not only that the work would now be Labour MP for Islington South and Finsbury Emily He said he was ‘unable to hide his carried out by the merged NHS Trust Thornberry frustration’ with the union, which had Development Authority/Monitor and walked out of pay negotiations with led by national patient safety director the Department of Health ‘without Mike Durkin but that it would be notice’ last year. He added that if an signed off by NICE, the Care Quality agreement could not be negotiated Commission’s chief inspector of by September, then new rules would hospitals Sir Mike Richards, and be imposed. Sir Robert Francis, who led the inquiry into poor care at Mid Staffordshire BMA leader Mark Porter called Hunt’s Foundation Trust. speech a ‘wholesale attack’ on doctors, and said the announcement But Mr Hunt stopped short of throwing was an attempt to disguise the lack his weight behind an official ratio of of clarity over how extra weekend nurses to patients in hospitals. He said staffing would be paid for. Dr Porter, he did not want to be prescriptive, and an anaesthetist working in the west that some of the safest hospitals in the Midlands, continued: ‘This is a blatant world had fewer staff than you might attempt by the government to distract expect. The Virginia Mason hospital from its refusal to invest properly in system in Seattle was the example the emergency care.’ secretary of state gave, and will be a The Virginia Mason The leading health think-tanks, the hospital in Seattle King’s Fund and the Nuffield Trust, both issued statements supporting a move towards 7-day working, but pointed out that it was not yet clear how much it would cost or how it fitted into the financial deal between the government and the NHS in the Five Year Forward View.

Jeremy Hunt’s speech also saw a significant reverse for NHS England’s policy on safe staffing. The National Institute for Health and Care Excellence (NICE), which sets binding quality standards for the service, had been

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name the NHS will be hearing a lot culture. Around 120 staff from the NHS more of over the coming years: this US Trust Development Authority will also non-profit corporation has landed a receive training in ‘lean’ management £12.5 million contract with the NHS, to techniques, similar to those used work with five English hospital trusts to by Toyota. improve culture and safety. Another potentially far-reaching Virginia Mason leader Gary Kaplan measure was the introduction MD is considered a guru of clinical of an Air Accident Investigation engagement for making his Branch-style safety body to sit organisation one of the safest in the within the newly merged Monitor world. After an avoidable patient death and Trust Development Authority. 11 years ago, the Washington-state The Independent Patient Safety healthcare system redesigned itself Investigation Service will have a ‘no on principles similar to the Toyota blame’ learning culture, similar to Sir Stuart Rose, former boss of Marks and Spencer production model. the airline industry. Mr Hunt said this approach in commercial aviation: ‘led The US firm’s work with the NHS to dramatic reductions in both fatalities will see Shrewsbury and Telford and cost – and we need to do the Hospitals Trust, Surrey and Sussex same in healthcare’. Hospitals Trust, Barking, Havering and Redbridge University Hospitals Trust, The health secretary also published the Leeds Teaching Hospitals Trust and report of former Marks and Spencer University Hospitals of Coventry and boss Sir Stuart Rose to coincide with Warwickshire each receive 10 days’ his speech. Commissioned in February worth of visits from the Virginia Mason 2014, Sir Stuart’s report was highly team to help them improve clinical critical of the confusion introduced

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Senior figures in the NHS suggest that ‘the system is into the NHS by the 2012 Health and Although perhaps his most trenchant creaking’ Social Care Act, saying the service criticism was of the system’s failure was ‘drowning in bureaucracy’ to support the managers it had because of the number of regulation entrusted with such difficult tasks. and oversight organisations. He Performance management across the said this had ‘spawned an industry service was ‘haphazard and weak’, of data collection’, and added: ‘All and providers had to field too many recent reforms have been about similar requests for information devolving the system. Now there is from the Department of Health and no one system leader; so all are vying NHS England. for territory.’ The Rose review also said there had Another area criticised by Sir Stuart been ‘enormous change in the NHS in was the abolition of strategic health the last 2 years’, and that staff were authorities. ‘The disappearance of the not able ‘personally or professionally [strategic health authorities] means to manage change and to make there is no one to lead any region in a themselves properly able to do what is collaborative reconfiguration over the asked of them’. longer term,’ he said. And the peer went further, criticising one of the Sir Stuart proposed increasing key principles of the Act: increasing ‘tenfold’ the size of the NHS graduate the role of competition in the NHS. recruitment scheme, which he Sir Stuart’s review was told by senior described as ‘woefully small’ at its figures in the NHS that ‘the system is current size. creaking … and that competition is causing harm, even that there has been Sir Stuart’s report was seen as a too much competition’. further step in distancing Mr Hunt

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from the legacy of his predecessor outright ignore as the NHS’s financial Andrew Lansley, whose reforms he and performance problems continue has often had to work around or to grow.

New ministerial team

May saw the appointment of pointed out that if Mr Hunt remains the first all-Conservative team of in post until spring 2016, he will health ministers since the Major become the country’s longest serving government of the mid-1990s. The health secretary. The new appointees only two ministers to carry on from are George Freeman as life sciences the previous team were Jane Ellison, minister, Ben Gummer as minister for who remains parliamentary under- care quality, Lord Prior of Brampton secretary of state for public health, as minister for NHS productivity and and Jeremy Hunt as the secretary Alistair Burt as minister for community of state. The Health Service Journal and social care.

TDA/Monitor merger

would be effectively merged – and in his 25-year vision speech Jeremy Hunt announced that the new organisation would be called NHS Improvement.

Although the two bodies will not be formally dissolved, the move is understood as a merger in all but name. If the combined organisation were to stay roughly the same size as the two separate bodies, it would have an annual turnover of £137 million. The new name is intended to reflect an increased focus on helping NHS provider trusts with the growing performance Monitor and the TDA will and finance challenges they will face. effectively be merged In June, Jeremy Hunt moved to The TDA was created by the 2012 dismantle another piece of the Health and Social Care Act that was regulatory landscape inherited from intended to see the Department of his predecessor Andrew Lansley. Health and the secretary of state for After months of speculation it was health step back from the day-to-day announced that Monitor and the NHS management of the NHS. Chaired Trust Development Authority (TDA) would share a chief executive. by Sir Peter Carr and led by former NHS deputy chief executive David In July the Department of Health Flory, the function of the TDA was to went further, and said the two bodies performance manage trusts that had

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Foundation trusts have been damaged by scandal not yet been conferred foundation 2014–2015 also forced an increasing trust status by Monitor. The authority number of trusts to rely on bailouts was also charged with preparing from the Department of Health, these organisations for assessment by further weakening the case for their Monitor, which would take over their being autonomous. performance management once they achieved foundation trust status. Although Monitor had initially been set up to authorise and regulate When foundation trusts were first foundation trusts, the Lansley reforms created in 2004 they were supposed had given it extra responsibilities as to be elite organisations that had an economic regulator, competition demonstrated they had the financial rules enforcement body and the setter competence to enjoy greater autonomy of treatment prices within the NHS’s from government – in the same internal market. And, in February this way as academy schools or housing year, Monitor announced it would associations. But the scandals at Mid be setting up a new division that Staffordshire Foundation Trust and would explicitly performance manage University Hospitals of Morecambe Bay foundation trusts more proactively – Foundation Trust, which were in part a move away from its original blamed on management teams cutting light‑touch role. staff in order to satisfy the financial requirements to become a foundation Policy teams at the Department of trust, damaged the brand. Health, Monitor and the TDA are still working on exactly how all these The continuing financial pressure felt responsibilities will be divided in across the sector over the financial year NHS Improvement.

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Both Monitor and the TDA had faced non-foundation trusts were no longer censure for the slow pace of trusts worth maintaining. achieving foundation trust status. Over the course of the coalition government, The TDA and Monitor also took part not many trusts were actually authorised of the blame for the deterioration in under Monitor’s rules, and several of the the financial position of the provider most financially crippled organisations sector as a whole. The financial were moved out of the foundation trust position of the trusts under Monitor’s pipeline simply by being merged. care in 2014–2015 worsened from a combined predicted deficit of The most significant hospital trust £10 million to a total of £349 million to become a foundation trust in this by the end of March this year, with period was St George’s Healthcare more than half of the 152 foundation Trust, which had to declare a trusts overspending. £10 million deficit shortly after authorisation. Monitor is carrying out Although the governance an inquiry into how the trust came to arrangements for the new joint be granted foundation status, which organisation will be thorny, the leaders is supposed to signify sound finances, of Monitor and TDA have already so shortly before it went into the announced their departures. TDA red. The St George’s incident was a chief executive David Flory left in June, considerable embarrassment to the having run the organisation since its assessment process run by the two creation. Monitor chief executive David organisations, and could have been Bennett announced he was leaving a factor in Mr Hunt deciding that the in the same month. Mr Bennett, a differences between foundation and former head of the Number 10 policy Leaders of both Monitor unit under Tony Blair, had been in the and the TDA have already announced their top job at Monitor since 2010, having departures overseen the considerable changes in the organisation’s role during the Lansley years.

As the Parliamentary Review went to press, front-runners for the chief executive job at NHS Improvement are thought to be either a high- profile figure from one of the large management consultancies or a well-respected hospital foundation trust chief executive. Whoever takes the role will have one of the most significant jobs in the NHS, answering directly to the secretary of state at a time when the financial position for individual hospitals and the service itself is worse than at any time in the past 15 years. Indeed, Jeremy Hunt told the King’s Fund in July that the performance challenge the sector faced was greater than at any time in the service’s history.

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Financing the NHS

2015 has seen the close of the worst the government would increase financial year for the NHS in more annual NHS funding by £8 billion than a decade – and anxiety that by the end of this parliament. But the financial year 2015–2016 could commentators pointed out that this be even worse. At the end of 2014– money was merely what was needed 2015, 80% of provider trusts were to account for the increasing and in deficit – a higher proportion than ageing population. ever before. The increasing inability of The £8 billion is what the service asked NHS organisations to set break-even the government for in the Five Year budgets puts increasing strain on the Forward View, a strategy document concept of the internal market in the produced by NHS England chief NHS, introduced in 1990. executive Simon Stevens. In exchange Trusts are predicting a deficit of more for this increase, the NHS is aiming to than £2 billion for the year, and senior deliver £22 billion of savings over the figures are concerned that the NHS next 5 years. overall could breach the Department of The Five Year Forward View was Health’s expenditure limit for the first commissioned in response to an time this year. analysis produced by Monitor in In his July budget, Chancellor October 2013. This calculated that if George Osborne confirmed that the NHS continued providing services The NHS aims to deliver £22 billion in savings in the next 5 years

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in the way it does at the moment, and the next – it now seems clear it will be with its current funding, then it would this year’. be running a £30 billion deficit by the end of the financial year 2020–2021. In its annual report for 2014–2015, published in July, Monitor’s chief The financial crisis facing the NHS executive David Bennett said his this year has been in the post for a organisation had reviewed the 5-year little while. Former NHS England chief plans for the 151 foundation trusts it executive Sir David Nicholson warned was responsible for, and only 30% had in the weeks before he was replaced a plan that saw them staying viable in by Simon Stevens that the NHS would 5 years’ time. need an extra £2 billion if it were to stay in balance in 2015–2016. And in Senior sources in the NHS believe that July 2014 the Nuffield Trust published the government will soon have to make a report called In the Red, in which it decisions on whether to increase the said that ‘the NHS seems destined to overall funding for the service or allow experience a funding crisis this year or it to make rationing more explicit.

The Carter review

in staffing, medicines management, hospital pharmacy and estate costs. The findings came from a study of procurement practices in 22 hospital trusts across England.

The Daily Mail reported Jeremy Hunt telling the NHS Confederation’s annual conference in Liverpool in June that some of the peer’s findings were ‘absolutely staggering’, and that the service had ‘failed to use [its] collective bargaining power’. Lord Carter’s interim report found one hospital trust paying more than double the price NHS procurement procedure has been paid by another for a box of toilet frequently criticised In June 2014, Jeremy Hunt commissioned rolls, and that some organisations a review into the oft-criticised world of were paying three times as much as NHS procurement. NHS bodies buy in others for syringes. The secretary of roughly £14 billion worth of goods and state also took aim at the range of services a year, and the government is different products the NHS bought, committed to reducing this significantly telling NHS managers: ‘Best practice in over the next 5 years. procurement says that you should have between 7,000 and 9,000 product Lord Carter, a Labour peer and lines on the NHS. We have 500,000 former head of the NHS’s competition product lines.’ authority, was tasked with helping trusts to make savings. His interim Lord Carter, who under the Labour report, issued in June this year, found government led a review of pathology significant efficiencies could be made services in the NHS, proposed a new

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measure of efficiency that would Lord Carter also suggested that the be applied to all hospitals and allow relationship between the suppliers them to be judged against their of high-cost medical devices may peers. In July, the new minister for have to be changed to increase NHS productivity Lord Prior said that standardisation. This could see the the measure was not intended to be purchasing decisions on these devices used as a league table in newspapers: taken at a regional level rather than ‘transparency can be cruel’. by individual hospitals. Lord Prior said in an interview with the Health Service Lord Prior, a former chair of the Care Journal that this could mark another Quality Commission, also said the significant departure from the idea government might adopt Lord Carter’s of foundation trusts as organisations Lord Carter suggestion of a ‘Sunshine Act’ to make able to exercise an autonomy they had sure relationships between doctors earned through efficient management. and the suppliers of high-cost medical He warned that trusts that tried to devices were above board. The Physician function as ‘islands’ over the coming Payments Sunshine Act was introduced years would fail. in the USA in 2010 to make relationships between providers and pharmaceutical Trusts are widely expected to start companies more transparent. sharing back-office and other functions in order to lower costs. July saw three Lord Carter’s report said there was a trusts announce a significant step in case for making disclosure of financial this direction. Although stopping short relationships between the two of a full merger, the Black Country mandatory in the English NHS. It also Alliance will see the Dudley Group of found that some hospitals were besieged with sales reps from medical device Hospitals Foundation Trust, Walsall companies, with one trust in Yorkshire Healthcare Trust, and Sandwell and having 65 on site at any one time. The West Birmingham Hospitals Trust peer said it would be ‘naïve’ to imagine work together to lower costs in the cost of these reps was not ultimately human resources, procurement, IT and borne by the NHS in the form of higher estates services. The three trusts have costs, and that a different relationship a combined turnover of more than with suppliers could be cheaper for the £1 billion, and serve a population of industry and the taxpayer. one million.

Staffing agencies and management consultancies

In December 2014 the Department of The issue sparked considerable news Health asked Lord Carter to expand the coverage, with a headline in The scope of his work on procurement to Daily Telegraph saying agencies were include the cost of agency staff to the ‘bleeding the NHS dry’. The paper NHS. The overall wage bill for agency published the names of the directors doctors and nurses for 2014–2015 was of the largest companies providing £3.6 billion – more than double what the temporary staff, along with pictures of sector had projected that it would spend. their homes.

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The issue received personal attention Hunt to complain that he had from the secretary of state, who said he ‘denigrated’ their industry, pointing would be introducing a cap on the total out that the fees paid to the agencies hourly rate available to staff and would themselves made up only a small ‘wean’ the NHS off ‘its understandable proportion of the total bill. Chief but growing addiction’ to using executive of the association Ann Swain agencies. He said: ‘Expensive staffing also said the government bore some agencies are quite simply ripping off of the responsibility after reducing the NHS. It’s outrageous that taxpayers the number of training places for are being taken for a ride by companies nurses and failing to ensure hospital charging up to £3,500 a shift for a trusts stuck to regional purchasing doctor. The NHS is bigger than all of framework arrangements that were these companies, so we’ll use our supposed to contain costs. bargaining power to drive down rates and beat them at their own game.’ If after the cap is implemented later this year some trusts will find it Hospital bosses said they were only impossible to properly staff wards responding to the pressures on their at the rates that the Department of services and that the government’s Health has set, and the government reaction to the Francis Inquiry had could be heading for a serious compelled them to increase the number confrontation with the service. of staff, particularly nurses, on shift at any one time. The high rates paid to some Minister for NHS productivity Lord doctors also reflect serious problems Prior admitted in an interview with recruiting to some specialist posts in more the Health Service Journal in July that, isolated areas of the country. although the second half of 2015–2016 would see a downward trend on The Association of Professional agency spend, he would not commit On-shift staff numbers have had to increase in Staffing Companies wrote to Jeremy to getting the overall agency total reaction to the Francis Inquiry

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lower than its 2014–2015 peak this lie in changing clinical practice to financial year. deliver better outcomes at lower cost, something that can only be achieved by There was further cause for gloom engaging NHS staff in a new mission to when the King’s Fund published a deliver better value.’ survey of NHS finance directors that showed less than one in ten believed The workforce picture was further the measures on agency spend would complicated by Chancellor George curb overall costs. The think-tank’s Osborne, who announced another chief economist John Appleby said in 4 years of public sector pay restraint, a statement: ‘There are considerable with wage increases held to 1%. opportunities to make productivity This contradicted the NHS’s own improvements, but continuing to rely planning assumptions in the Five Year on top-down policy levers such as Forward View, and the Royal College limiting staff pay increases and capping of Nursing said the move would ‘have agency fees will not be sufficient. a significant impact on the recruitment The most promising opportunities and retention of staff’.

Performance targets

The financial year 2014–2015 was not key measures. The target of 95% only a poor one for finance directors. of accident and emergency (A&E) Performance across England fell, and attendees being seen within 4 hours Several performance failed outright against a number of was missed, as was the commitment objectives have not been met in relation to key measures

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to treat 90% of patients waiting for an lack of social care provision. No one elective procedure within 18 weeks. in the sector expects this situation to get much better over the rest of 2015, Performance at A&E departments was although efforts at closer working with particularly worrying as the overall councils are being made, most notably attendance was down from January with the Better Care Fund. to March compared with the previous year. Hospital managers said the real The situation in A&E has hampered problem for A&E came further along hospitals in their efforts to treat in the process, as the average length patients for elective procedures. of stay in hospital had increased, Beds taken by emergency admissions reducing staff’s capacity to admit often saw last-minute cancellations new patients. of planned operations, while several trusts, including Barts Health Trust, had Monitor’s analysis of foundation trust to suspend their reporting of waiting performance put at least some of the times data entirely as they uncovered blame on local councils. The regulator’s backlogs of untreated patients. data said the overall number of delayed transfers of care, usually to local The decline in elective surgery authority-commissioned facilities, had performance has been steady over the risen by nearly 10% year on year in past 2 years, and in 2014–2015 was the fourth quarter, and that nearly a particularly marked in general surgery, third of them were attributable to a urology and orthopaedics.

North Cumbria PFI

whose responsibility it was to ensure fire safety at the Cumberland Infirmary showed the tenacity of some of the problems inherited from the Labour government. The dispute acquired a new urgency after the local fire authority put an enforcement notice on the building in July.

North Cumbria University Hospitals Trust is ‘buddied’ with Northumbria Healthcare Foundation Trust, under a scheme set up by Jeremy Hunt to encourage more successful trusts to help underperforming organisations. NHS services are under strain Away from Whitehall, the NHS world Northumbria was widely heralded in saw significant upheaval as services the NHS for a pioneering deal that saw faced a worsening financial position it borrow enough cash from its local and increasing demand. council to pay off its PFI deal, saving the taxpayer money. A dispute between North Cumbria University Hospitals Trust and its private In a significant move, Northumbria’s finance initiative (PFI) partner over chief executive Jim Mackey criticised

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North Cumbria’s PFI deal, saying: rather than being caught up in legal ‘The PFI contract has crippled the negotiations which are preventing us trust financially yet the building in making progress.’ which patients are being cared for is sub-standard. We must take action It would mark another significant break to terminate the PFI contract, as we with the recent past if the NHS were have done elsewhere in the country. allowed to buy itself out of more PFI This would allow us to take control deals, some of which have repayment of the hospital’s estates management schedules running over decades.

NHS top posts

Barts Health Trust in east London was created from the merger of three smaller trusts in 2012, and with a turnover of more than £1.25 billion it is the biggest NHS trust in England. In March the trust was put into special measures after inspectors found evidence of poor care and a culture where some staff felt too intimidated to share concerns about patient safety.

When inspectors visited the trust’s Whipps Cross University Hospital they found insufficient staff working in a Several famous hospitals culture of bullying and low morale have had management plus a failure to meet waiting time to improve performance at the issues targets. Almost the entire senior Princess Royal University Hospital in management team have now been suburban Bromley. King’s had taken replaced, including the chair, chief over the smaller hospital in 2013 executive, finance director and director after Andrew Lansley dissolved its of nursing. The interim chief executive parent organisation, South London is Alwen Williams, formerly the NHS Healthcare Trust. This was the first Trust Development Authority’s director time the legal powers had been used – for London. and the messy fallout in the capital has dissuaded policy-makers from Barts was not the only famous hospital using it again. to run into significant difficulties this year. King’s College Hospital Recent years have increasingly seen the Foundation Trust in south London NHS look outside of the UK to recruit saw its chief executive step down to the top posts in its largest hospitals. in April after Monitor was forced to Dr Tracey Batten took over the appoint a turnaround director. The running of Imperial College Healthcare trust, a member of the prestigious Trust in 2014, and fellow Australian Shelford Group, which represents the Dr Keith McNeil was appointed biggest and most respected teaching as chief executive of Cambridge and research hospitals, had struggled University Hospitals Foundation Trust in

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November 2012. Another Antipodean, charge of Oxford University Hospitals Dr Peter Steer, took the top job at Trust in October, having left his job Great Ormond Street Hospital for running one of Holland’s largest Children Foundation Trust in May hospital chains. 2014, and Dr Bruno Holthof will take

Manchester reconfiguration

Long-awaited news from Manchester Manchester Royal Infirmary, Salford on its ambitious reconfiguration Royal Hospital and Royal Oldham programme arrived in July. The Hospital and Stepping Hill Hospital in process had caused considerable Stockport are the designated centres. controversy in Greater Manchester, with surgeons at University Hospital of Greater Manchester could also soon South Manchester Foundation Trust be blazing a trail in integrating health complaining it was flawed. and social care budgets. Part of Chancellor George Osborne’s plans The reconfiguration saw just four for a ‘northern powerhouse’ involved of the region’s ten hospitals classed moves to integrate the commissioning as specialist sites able to provide of services across the ten local emergency and high-risk general authorities. Although welcomed as a surgery. University Hospital of South step towards devolution, health policy Manchester, the Royal Albert Edward experts are still waiting for detail on The Chancellor, George Osborne Infirmary in Wigan and Royal Bolton where power will actually lie in the Hospital will all now lose this service. new system.

Shelford Group revolt

One of the most significant events specialist care in England – said new in the provider sector this year was payment rules would cost them more a revolt over money by England’s than half a billion pounds, and damage teaching hospitals. For the first time patient care. since the introduction of the internal market, hospitals rejected proposals by In a consultation exercise, NHS England and Monitor to change three‑quarters of them, measured the way that organisations were by annual turnover, voted to reject paid by commissioners for the work the proposals. When NHS England they did. and Monitor came back with new proposals, 22 of the trusts opted Spearheaded by the Shelford to stay on the payment system that Group – which represents the ten covered 2014–2015. most prestigious teaching hospital trusts in England – trusts forced NHS The revolt marked a significant test England and Monitor to go back to of the power of NHS England chief the drawing board on their payment executive Simon Stevens, who was plans for 2015–2016. The trusts – faced with a nightmare scenario of which perform the bulk of expensive, powerful hospital trusts who could

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Mr Stevens faced a backlash from powerful potentially take the government to the 2016–2017 financial year begins, hospital trusts judicial review on the issue while the NHS England may find itself in a general election campaign was in full stronger negotiating position. swing. When the planning round for

Hinchingbrooke back to the NHS

Another issue inherited from the a rating of ‘inadequate’ in January, Lansley era was partially resolved although after Circle complained in April, when management of about the methodology used by the Hinchingbrooke Healthcare Trust in commission this was raised to ‘requires Cambridgeshire was handed back to improvement’ in April. It Circle also the NHS from private company Circle. recorded spending deficits, some of which Circle was obliged by its 10-year Circle, which runs private hospitals contract to absorb. across England, had won the franchise to run the small district general hospital The failure of the Hinchingbrooke in 2012. However, after an investment franchise seriously damaged the in staff and a public relations blitz, concept of franchising out the the organisation ran into financial and management of trusts to private firms, performance difficulties. and the idea has now been largely supplanted by the concept of NHS-run An inspection by the Care Quality hospital chains, as set out by Simon Commission saw the organisation given Stevens and Sir David Dalton.

18 | reiw v e of the year HEALTHCARE EDITION

Simon Stevens’ Five Year Forward View

In October 2014, NHS England chief June saw three areas placed in the executive Simon Stevens released the ‘success regime’, the Five Year Five Year Forward View, a document Forward View’s new process for in which he set out his vision for how dealing with health economies that the service must change by 2020. The had significant financial and/or 41-page policy document was widely performance problems. The three areas seen as a bargain with the government, chosen for the regime were Essex, setting out how the NHS would reform Cornwall and North Cumbria. For the itself in exchange for the money it needs first time the system, while deploying to keep up with the growth in demand. fairly conventional performance management tactics, will be applied Released 6 months into Mr Stevens’ to a whole geographical area, rather tenure, the document was welcomed than individual organisations. This is by secretary of state for health Jeremy an attempt to surmount the problems Hunt, and the financial commitment currently faced by regulatory bodies was honoured by Chancellor George that are called in to deal with issues at Osborne in this year’s budget. The one particular trust but find they have document committed the service to no power over other organisations in significant changes in the organisation the same area which might be part of of hospitals, GPs and community care. the problem. Mr Stevens’ Five Year Forward View details his vision for change in the NHS by 2020

reiw v e of the year | 19 THE PARLIAMENTARY REVIEW Highlighting best practice

More stress could have been placed on the The document also set out a number of back new initiatives on smoking, importance of improving public health different organisational forms that the obesity and alcohol abuse. NHS could adopt in order to provide more integrated care over the next But Mr Stevens also promised that 5 years. This could see hospital trusts list-based primary care would remain taking over the running of primary care the ‘foundation’ of NHS care, although in some areas, while in others groups he recognised that a new deal was of GPs will be licensed to run their needed for GPs, and promised more local district general hospital. A series investment. He also pledged to speed of ‘vanguard’ applications for taking up the recruitment of new GPs and to forward these new organisational ‘stabilise’ the funding of primary care forms were solicited, and funding for over the next 2 years. the frontrunners is expected to be announced later this year. Long-stalled moves to allow patients to control their own budgets for treatment The Five Year Forward View also saw were also pledged, with the option a candid admission that the NHS, of combined health and social care although much improved over the budgets and increased support for the past 15 years, had failed to heed the 1.4 million full-time carers in England. warning of Derek Wanless’s health review about the importance of The big question facing the NHS as improving public health. Mr Stevens it prepares for another tough winter said the NHS was now ‘on the hook is whether it can take these steps for the consequences’, and promised towards new organisational forms a ‘radical upgrade in prevention and in the face of mounting finance, public health’, and that the NHS would performance and staffing issues.

20 | reiw v e of the year HEALTHCARE EDITION NHS Tameside and Glossop Clinical Commissioning Group

Dr Alan Dow, Clinical Chair espite facing a number of challenges, and serving a ABOUT NHS TAMESIDE population with some of the worst health problems AND GLOSSOP CLINICAL Din the country, NHS Tameside and Glossop Clinical COMMISSIONING GROUP Commissioning Group (CCG) has placed itself firmly into the » Clinical Chair: Dr Alan Dow forefront of organisations working to turn the rhetoric about » Chief Operating Officer: health and care integration and new models of working into a Steve Allinson reality. Its ambitious Care Together programme seeks to push » Serves Tameside and Glossop integration well beyond the point so far reached anywhere else through 41 practices in the country. Here Clinical Chair, Dr Alan Dow, and Chief Operating Officer, Steve Allinson, describe the journey. Steve Allinson, Chief Operating Officer It is crucial to understand the sheer scale of the ambition needed to transform both health and social care. Life expectancy for men and women is lagging around 2.5 years behind the national average. The proportion of people with heart disease in Tameside is one of the worst in the country and the area also has worse than average rates for a range of other conditions.

Combine that with the area being part of the South Manchester ‘challenged’ health community, a looming potentially crippling debt problem and a local acute NHS foundation trust still in special measures following a 2013 Keogh Review, and the picture coming into focus looks almost unremittingly bleak.

However, as Steve Allinson says: ‘In some ways, being in a challenged situation isn’t that relevant – the discussion needs to be about the individual and front line services. The shared ambition we have with Tameside Metropolitan Borough Council (TMBC) means that we have agreed to put the things that preoccupy each

NHS TAMESIDE AND GLOSSOP CLINICAL COMMISSIONING GROUP | 21 T LAHE PAR I MENTARY REVIEW Highlighting best practice

of us as individual organisations to one and shore up an unsustainable system side. This shared ambition to focus on built around an acute hospital. the individual then translates into a shared ambition for the system.’ That will, of course, mean major ramifications for Tameside Hospital So what does the Care Together NHS Foundation Trust, which has programme involve? On one level, the prompted Monitor to appoint a The Care Together programme’s answer is simple – joint commissioning team of independent experts from four levels of care with TMBC of a truly integrated health PricewaterhouseCooper to act as a and care service model, with the large Contingency Planning Team (CPT). Building up the strength majority of services procured from a Their role is to examine the Care of communities new kind of unified health and social Together plans – and, in particular, care provider that has its main focus on the desire to create a single new Local Community community services. provider organisation – in forensic Care Teams detail. In summer 2015, the CPT will The reality, though, is much more report to Monitor, giving their view on nuanced. Joint commissioning between whether or not Care Together could Specialist pathways the CCG and the local authority for work. If so, they will set out a plan for Tameside is already a done deal, and its implementation. If not, they will talks are underway over how to achieve Hospital-based care advise which alternative approach or the same end for Glossop, which falls approaches would. under High Peak District Council and Derbyshire County Council. The health Local GPs and their teams will be key to and care community is facing a budgetary the success of the programme. Dr Alan problem of mammoth proportions. Dow added: ‘As well as our collegiate Without radical action, there will be a approach with the local authority, we £74 million hole in the finances by 2019. also have broad consensus amongst our GP community that Care Together is Dr Alan Dow said: ‘The reality is that the right way to go. As a membership around £50 million of that deficit is in organisation, that is essential. social care. But there is a strong and the Care very widely held feeling amongst local ‘But what has already been achieved GP practices that the time for health is remarkable. We have created a new Together and social care operating separately is modus operandi through bringing very “ programme well past its sell by date. Collaboration different organisational cultures and with the local authorities, particularly funding regimes together, and aligned involves joint their Health and Wellbeing Boards, our shared commissioning intentions

commissioning has led to a unified approach – the with the health and social care “Wellness Offer” – to tackling some of objectives of each organisation.

of a truly the wider determinants of health.’ ‘This is no longer merely theoretical. The aim is to tackle the area’s health integrated“ We have signed up to sharing a and care challenges across a number £170 million budget in 2015–2016, health and of fronts. Prevention and greater potentially rising up to £400 million supported self-care will reduce reliance annually as full integration is achieved. care service on services. At the same time, moving model as much care as possible into more ‘For me, the move towards accessible community-based venues and co‑commissioning with the local the creation of multi-disciplinary, flexible authority is every bit as exciting community-based teams to support as the more eye-catching and those with multiple/complex needs will headline‑making aspects of Care turn the focus onto personalised care Together, such as the creation of a rather than finding ways to perpetuate new provider organisation.’

22 | NHS TAMESIDE AND GLOSSOP CLINICAL COMMISSIONING GROUP HEALTHCARE EDITION

If Tameside was a village of 24 people with 100 people … 7 people under the age of 5 hypertension

17 people aged 5–19 5 people with CHD 1 person with atrial fibrillation 7 people with CKD 59 people aged 20–64 5 people with COPD

7 people with asthma

1 person with epilepsy

5 people with diabetes 13 people aged 65–79 2 people with cancer

6 adults (18+) with depression 4 people over 80

2 adults (18+) with learning disabilities 21 obese adults (16+) 1 person with dementia 1–2 people admitted to hospital for a condition related to alcohol use 17 adults (18+) 21 binge-drinking adults (16+) who smoke

= Children in poverty (0–19 years old), people in receipt of out-of-work = Reduction needed to reduce Tameside numbers benefits (20–64), in receipt of pension credits (65–79 and 80+) to England average

So where are local GPs, patients The recently announced plans for to make this work. Given what we and residents in all this? An devolution of the £6 billion health are facing in the immediate future, important conversation with GPs and social care budget to CCGs something radical has to happen is underway as the new provider and local authorities in Greater and it has to happen now. In many could, if it fully embraced primary Manchester also, argues Steve ways, being in such a challenged care provision, have implications Allinson, helps to pave the way for position locally is actually acting as for GPs’ employment and/or innovative approaches to integration. a beneficial catalyst for the kind contractual status, not to mention of radical reform that it would ‘What Greater Manchester their income streams. It would be easier –and certainly more devolution means is that other be stretching the truth to say comfortable – to run away from. CCGs and councils in the area are unanimity of view exists. However, now looking to be at the point it is fair to say that broad consensus ‘But what we have isn’t just the we have reached in Tameside and does, and there is a real appetite opportunity to dig the local health Glossop in about a year’s time. for pursuing the conversation to and care system out of a big hole – we have the chance to create a mutually acceptable conclusion. ‘Simon Stevens’ Five Year Forward something really special which will This would see GPs very much in View has set a new agenda for the deliver the care and services people the driving seat of commissioning, NHS, and it’s all about integration working together to become a and creating local solutions deserve and have every right to more influential and integrated and ways of working to fit local expect. In other words, we have to body of providers, with the focus on circumstances. What that landmark do something radical or the system improving health as well as services. document contains could just as will collapse but we want to do easily have been written about what we have set out in our Care Local people have been listened to Tameside and Glossop 2 to 3 years Together programme because of at a series of events over the past ago. Someone has to be the first the benefits it will bring to patients 2 years, including three major events to attempt something on this scale and local residents. in October 2014 where a set of and with this amount of ambition, nine business cases that comprise ‘Put simply, we want to do the right and it might as well be us. the core elements of Care Together thing because that, in itself, is the were discussed in detail and greeted ‘There is a huge amount at stake right thing to do.’ with a resounding ‘Yes please!’. and we don’t have the option not

NHS TAMESIDE AND GLOSSOP CLINICAL COMMISSIONING GROUP | 23 THE PARLIAMENTARY REVIEW Highlighting best practice Liverpool Heart and Chest Hospital NHS Foundation Trust

The daily safety huddle focuses on identifying and resolving safety and operational risks

Jane Tomkinson, Chief Executive ospitals are dangerous places; from near misses to never events, patients can be at risk of harm when entering the Hvery place they come to for care and treatment. Liverpool Heart and Chest Hospital NHS Foundation Trust, the country’s ABOUT LIVERPOOL HEART AND CHEST HOSPITAL NHS largest single-site specialist heart and chest hospital, is clear on FOUNDATION TRUST its zero tolerance of harm. As well as the main benefit for the » The UK’s largest single-site patients and their families there is good economic sense in this; heart and chest hospital harms cost in terms of extended inpatient stays, extra drugs and » Treats 13,000 inpatients and diagnostics, and may result in costly litigation. 78,000 outpatients each year

» A catchment population of Our Safe from Harm Vision was launched in 2013 with the aim of embedding a 2.3 million from the North culture of safety through a network of patient-safety champions. These champions West, Isle of Man and Wales have undertaken formal training with the Advancing Quality Alliance, an NHS » Increasingly seen as the Health and Care Quality organisation, and are key to delivering the safety initiatives national provider of choice prioritised by the trust’s Patient Safety Group. This group includes a number of for complex aortic surgery dedicated patient representatives who give up their time on a voluntary basis to » 210 beds, 1430 staff provide a patient perspective to discussions.

» Turnover £120 million Very clear objectives to reduce harm have been set by the Patient Safety Group and » Provides an exceptional the Board of Directors. These include: community-based COPD » reducing mortality by 20% by 2019 and CVD service » eliminating the most severe pressure ulcers (grade 3 or 4) » Number one for care and experience » reducing minimal harm ulcers by 50% (grade 2) » reducing avoidable falls by 50%

24 | LIVERPOOL HEART AND CHEST HOSPITAL NHS FOUNDATION TRUST HEALTHCARE EDITION

An important aspect of the “ safety culture is the high visibility of the

hospital’s senior » eliminating the blood-borne infection Through regular executive walkabouts

MRSA it became clear that front-line staff management » 97% harm-free care as measured by were reporting and managing risks and their “ the NHS Safety Thermometer. and incidents but there was a lack of awareness at senior management level commitment In addition, the trust’s membership has of the themes and trends emerging at played an important role in setting their operational levels. to the safety top four safety and quality priorities: In October 2014 the Board of Directors agenda » ‘always’ events for vulnerable patients attended a master class on quality » families as care partners and safety run by the North West’s » patients discharged home by lunchtime Advancing Quality Alliance, and was impressed by the work undertaken by » report, escalate and talk about Jim Reinertsen and Jamie Orlikoff to concerns. enhance safety in their hospitals in the An important aspect of the safety USA through daily safety huddles. It culture is the high visibility of the was from this session that the Liverpool hospital’s senior management and their Heart and Chest Hospital safety huddle commitment to the safety agenda. was created.

» CASE STUDY Top four safety and quality priorities Issue raised ‘Always’ events Ward managers had highlighted difficulties in securing extra staff to for vulnerable support patients who need ‘specialing’ – one-to-one observational care patients for those with dementia and other conditions. Generally, agency or bank staff were used (at premium rates), who were unfamiliar with the Report, escalate Families as hospital’s ethos of care. and talk about care partners concerns Action taken After this issue had been flagged at a number of huddles, it was clear that a trust-wide solution was required. Ward managers have now Patients home developed a strategy and an enhanced recruitment campaign to routinely by lunchtime provide this care from a pool of Liverpool Heart and Chest Hospital staff.

LIVERPOOL HEART AND CHEST HOSPITAL NHS FOUNDATION TRUST | 25 T LAHE PAR I MENTARY REVIEW Highlighting best practice

visible, and at the end of the month are reviewed by the huddle membership to confirm that appropriate actions have been taken to manage the safety risk. On a practical level, many issues are resolved immediately as huddle members offer solutions and help.

Six months in and front-line staff are seeing the benefits of the huddle, practically, culturally and supportively. Feedback from ward managers includes:

‘Nothing is passed over, everything is transparent and on the table.’ Issues are put on a whiteboard (Day Unit Manager) in the executive corridor so that they are highly visible The huddle, led by myself or, in my ‘A huge amount of value for absence, the Director of Nursing and us from the CEO and executive Quality meets daily at 9.30 am for knowing about what is happening 15 minutes. The huddle is open to on the shop floor every day.’ anyone across the trust who has a (Catheter Laboratory Manager) concern about safety or a risk that may affect patients or staff, but the core ‘Issues are resolved rapidly, even membership generally includes the those that have dragged on ward managers, heads of departments for years.’ and heads of nursing. A quick check (Ward Manager) is made on beds and nurse staffing ‘A sharing of problems makes us levels, but the focus is on incidents that know we are not alone.’ have occurred in the previous 24 hours and emerging operational risks. Issues (Ward Manager) raised are many and varied, and the The safety huddle is a quick and table below summarises a number that effective way for executive directors were raised as single issues but, in fact, to become aware of patient safety manifested multiple times or in multiple risks and for front-line staff to be areas, showing a trend of safety risks. empowered to take immediate action. Attendance and issues are logged daily, Relationships are vastly improved by and minutes are routinely reviewed this regular contact, and the Board can by the Director of Nursing and Quality gain assurance from the daily huddle as to identify trends and themes. Issues well as the robust processes to address are recorded on a whiteboard in the safety risks before they become events. executive corridor so that they are highly

Issue raised Actions taken Incorrect data on theatre listings Enhanced standard operating procedure and computerised listing No maintenance or cleaning of drugs trollies Routine servicing and decontamination of all drugs trollies Pressure stockings not replaced once the patient has Formal agreement to replace pressure stockings left the hospital setting Patient training on diabetic patient management Enhanced diabetic training for all healthcare assistants Delays in patient consent Refreshed consent procedure developed and communicated No hospital telephone number on patient wristband New wristband containing hospital information

26 | LV I ERPOOL HEART AND CHEST HOSPITAL NHS FOUNDATION TRUST HEALTHCARE EDITION The Royal Marsden NHS Foundation Trust

The Royal Marsden, Chelsea Cally Palmer CBE, Chief Executive, The Royal Marsden hen it opened in 1851, The Royal Marsden was the first hospital in the world dedicated to treating cancer. Its founder, William Marsden, had a vision to create ABOUT THE ROYAL MARSDEN W NHS FOUNDATION TRUST a pioneering cancer hospital dedicated to the treatment and care of people with cancer and research into the underlying » With our academic partner, causes of cancer. Today we continue to build on this legacy as The Institute of Cancer a world-leading cancer centre specialising in cancer diagnosis, Research (ICR), we are the largest and most treatment, research and education. comprehensive cancer centre in Europe, and one of the top five in the world Our academic partnership with The Institute of Cancer Research (ICR) makes us the largest comprehensive cancer centre in Europe. Through this partnership, we » We treat over 50,000 undertake ground-breaking research into new cancer drug therapies and treatments patients every year for children and adults. » Our state-of-the-art 19-bed We have two hospitals: one in Chelsea, London, and the other in Sutton, Surrey. Critical Care Unit is the only Also in Surrey, we have a Chemotherapy Medical Day Unit at Kingston. In April one in the UK providing full 2011, the trust became responsible for all the childrens’ and adult community intensive care exclusively for services for the boroughs of Sutton and Merton. Together we are ensuring that cancer patients treatment and care is of the highest quality and is seamless between hospital » We are the only Biomedical and home. Research Centre specialising in cancer The trust has always been committed to working in partnership with organisations internationally and nationally. Locally, the trust is the host and one of the founding » We are the leading centre members of the London Cancer Alliance (LCA), which brings together 16 hospitals for cancer clinical trials in in west and south London and over 3,000 cancer clinicians to improve the care the country, running over of patients. The Alliance has created common data sets to drive change and 400 trials each year improvement in the quality of cancer care for 5.9 million people.

THE ROYAL MARSDEN NHS FOUNDATION TRUST | 27 T LAHE PAR I MENTARY REVIEW Highlighting best practice

As a trust we are also aware that our are some examples of our advances most precious resource is our staff, and in imaging, surgery, radiotherapy and that effective staff engagement and chemotherapy: optimum staff care is a prerequisite to good patient care. In 2014–2015 we » Imaging. Through the generosity of In 2014–2015 have continued to invest in our staff and The Royal Marsden Cancer Charity we have to recognise their achievements, both as UK, patients are able to access a individuals and as teams, in furthering our revolutionary new technique for the “ seen several therapeutic, research and education aims. diagnosis of prostate cancer. The Koelis Urostation combines the images incredible obtained from magnetic resonance world firsts, Where we lead at imaging (MRI) and 3D ultrasound The Royal Marsden technology to create an accurate which were The early diagnosis and detection of image of the prostate. This technique cancer is vital to improving 1- and 5-year provides much more information made possible and overall survival. It is thought that one than a standard blood test and biopsy. through the of the key reasons why cancer survival in This new imaging will ensure faster

the UK is behind that in some European access for diagnosis and is a much dedicated work countries is delay in diagnosis and the less invasive procedure for patients.

of our clinicians start of effective cancer treatment. » Surgery. Once prostate cancer In 2014–2015 we have seen several has been diagnosed it is key that in translating“ incredible world firsts, which were made men who require surgery are able possible through the dedicated work to access effective research-based research of our clinicians in translating research treatment quickly. For these men the into cancer into cancer treatment. trust has invested in a larger clinical team, including expert consultant treatment One of the most common cancers surgeons and specialist nurses, and in men is prostate cancer and The new state-of-the-art equipment Royal Marsden has an internationally with a second da Vinci robot, the recognised research programme in male da Vinci Xi, again thanks to The cancers. This year saw several new firsts Royal Marsden Cancer Charity. in the research and treatment of men The robot allows the surgeon to with prostate cancer. The following A physiotherapist helping a perform microscopic surgery with young patient at The Oak Centre great precision, ensuring complete For Children and Young People removal of the tumour with much less damage to critical surrounding tissues. To ensure that the learning from The Royal Marsden can be adopted quickly across the UK the trust has launched a new Robotic Fellowship, the first of its kind in the UK, which will facilitate the training of up to 30 specialist surgeons. » Paediatric cancer. The Royal Marsden treats children from one year old and has a wonderful state- of-the-art facility for children and young adults with cancer. The Oak Centre for Children and Young People has 30 beds and sees over 600 admissions a year. In this very specialist unit children are rulers of

28 | T AHE ROY L MARSDEN NHS FOUNDATION TRUST HEALTHCARE EDITION

their domain. Everything has been designed with the child in mind; indeed, children, young adults and their parents were involved in every stage of the design. Children benefit from the close relationship between the trust and the ICR, with the largest drug development unit in the UK, studying new medicines for children. This relationship means that children benefit quickly from access to new translational research. Children undergoing intensive treatment often require long periods of hospitalisation, and it is essential that during their stay everything is done to minimise their discomfort. The facility has a dedicated catering Royal Marsden surgeons use the da Vinci Xi robot in theatre for team that works with every child the first time to determine their individual likes healthcare assistants. The programme and dislikes, and the children enjoy will be extended in the future to porters personalised support from play and catering staff. » OUR SPECIAL therapists and educational and FACILITIES psychological support teams. The Royal Marsden has also led a GP-training programme on all aspects da Vinci S surgical system – » Radiotherapy. The Royal Marsden, of cancer care for over 5 years, introduced in 2007, this robot in conjunction with the ICR, will with hundreds of GPs attending or allows surgeons to make be the first organisation in the UK participating via podcasts. microscopic incisions with greater to gain access to a revolutionary accuracy and control than ever radiotherapy system, the MR Linac. There is recognition from the board before; in 2015 we were the first This new technology uses MRI to right through the organisation that hospital in England to introduce improve dramatically the accuracy everyone at the trust makes a difference the newest model, the da Vinci Xi. and effectiveness of high‑precision to patient care and experience. This was Oak Centre for Children and radiotherapy. reflected at the trust’s first Schwartz Young People – one of the Round, where speakers ranged from largest comprehensive children consultant surgeons and nurses Everyone at The Royal Marsden and young people’s cancer to dietitians and porters. Schwartz makes a difference centres in Europe. Rounds, which originated in the USA, Across the trust there are dedicated staff are designed to give all staff across the The West Wing Clinical who are committed to continuous quality hospital time to reflect on what is really Research Centre – another improvement. In recognition of this the important about caring and to listen to example of how the trust trust opened its own postgraduate school each other. is investing in its research over 10 years ago, training most UK infrastructure, delivering cancer nurses, and has a progressive and Above all, The Royal Marsden is personalised medicine and proactive education and training policy. passionately committed to improving the translating scientific findings All staff have access to a generous study research, education and care of people in to the clinic. leave budget, and ongoing professional with cancer. It is intent on recruiting The Reuben Foundation development for all staff is very much the best people, listening to them and Imaging Centre – includes two encouraged. Such development includes ensuring they are able to develop so that state-of-the-art 1.5 T and 3 T MRI speaking at international conferences, they have the energy and the expertise scanners and two CT scanners, master’s and doctoral programmes for to further the science and care for enabling the trust to remain at the nurses and allied health professionals, children and adults with cancer. forefront of cancer diagnostics. and the Cavendish Care Certificate for

T AHE ROY L MARSDEN NHS FOUNDATION TRUST | 29 T LAHE PAR I MENTARY REVIEW Highlighting best practice Northamptonshire Healthcare NHS Foundation Trust

Medical Director, Alex O’Neil-Kerr and the ECT Team

Chief Executive Angela Hillery and Ward Matron Kerry Flatman orthamptonshire Healthcare NHS Foundation Trust (NHFT) provides a comprehensive range of physical, Nmental health and specialist services, tailoring care to the individual needs of our patients, service users, carers and ABOUT families. We provide care through GP practices, health centres NORTHAMPTONSHIRE and people’s own homes as well as our hospitals and hospices. HEALTHCARE NHS FOUNDATION TRUST Our focus is on accessible, convenient and integrated care – care with compassion. » A community and mental health trust

» 4,400 staff offer care to We all know that there is both uncertainly and complexity in the NHS. This provides more than 700,000 people challenges in finding new solutions as well as opportunities to be innovative. Demographic changes and population growth are inescapable. In particular, this is » Services are provided from placing increasing demands upon all our services, alongside increasing expectations a large number of sites, associated with technological advances too. including home based, hospitals, GP surgeries While so much around us changes, our values remain constant: and clinics » People first, working together for patients in everything we do. » Sites across Northamptonshire, including in Corby, Daventry, » Respect, dignity and compassion by valuing each person as an individual. Kettering, Northampton and » Improving lives by improving health, wellbeing and people’s experience of the NHS. East Northants » Dedication to quality of care and getting the basics right. » Everyone and equality count, and everyone is treated equally.

We have a responsibility to provide quality health and wellbeing services to the communities we serve and to listen and respond to their views in order to improve their experiences and care. Part of this is developing new ways of working. Here are

30 | NORTHAMPTONSHIRE HEALTHCARE NHS FOUNDATION TRUST HEALTHCARE EDITION three examples of work within NHFT Getting truly involved – that as Chief Executive I feel really improving services together proud of. Involving patients, service users, carers and our staff in the development of Letting our staff shine our services is key to how we evolve, grow and improve as an organisation. Electroconvulsive therapy (ECT) is used Meaningful patient involvement can for the treatment of severe depression, be hard to get right, but now we are catatonia or mania. It gives fast, We have taking big steps to address this and I short-term improvement to symptoms am really happy with our progress. developed when all other treatment options have failed, or when the situation is Initially, we held an ‘Involvement “ a nurse-led life‑threatening. Week’, with events, workshops and a ECT training chance to meet our involvement team NHFT was chosen by the Royal College at different locations. The highlight package, which of Psychiatrists to be part of an of the week was a showcase of innovative study evaluating the effect involvement activity being undertaken is currently of using trained nurses, rather than by different services. This gave an trainee psychiatrists, to administer undergoing opportunity for staff to share work they ECT. To date, two of our most senior

were proud of, and a chance to get accreditation nurses have been trained to administer new people involved and interested in

ECT treatment when prescribed by a working together to shape our services by the Royal consultant psychiatrist, and they have in the future. completed over 40 treatments. College of “

We have developed a nurse-led ECT What are the benefits? Nursing. It is training package, which is currently Enabling our patients, service users, the only training undergoing accreditation by the Royal carers and staff to be part of shaping College of Nursing. It is the only our services and strategic direction of its kind training of its kind. provides us with invaluable input and feedback on how we are doing. What are the benefits? We began revisiting our involvement For our patients we are providing a processes by creating a working group holistic pathway of care. They have made up of service users and staff who one contact through the procedure worked together to develop a booklet and fewer people around them. explaining what involvement means to Appointments are less likely to be Get involved: service user Dora recruits new members cancelled and more likely to run on time. All these factors reduce anxiety and improve patient experience.

For our staff, nurses are becoming more confident, knowledgeable and helping patients to improve.

We are developing a team of expert clinicians who can administer ECT, and will be able to offer others an accredited training course and share the results from our evaluation. Working in this way brings benefits to all involved, and we are very proud of everyone who made this a possibility.

NORTHAMPTONSHIRE HEALTHCARE NHS FOUNDATION TRUST | 31 T LAHE PAR I MENTARY REVIEW Highlighting best practice

return to base to hand over and make allocations for the next day. This was causing several issues, including:

» evening staff not having a proper handover » if a patient had either deteriorated or could be discharged they would have to wait until 2 pm, or possibly the next day » risks associated with lone working.

What are the benefits? The team introduced a new system where a senior nurse, therapist and a deputy are available on the Intermediate care team Live telephone. Staff phone in after seeing Handover every patient to discuss their visit. NHFT, key principles and information If a patient needs further help this on how people can get in touch. can be arranged, or if they are ready to be discharged this can happen We are now using this booklet within immediately. The system provides staff our services, and building a database with supervision and reassurance, with of interested patients, service users, the added benefit that their location is careers and staff. Each person is asked known in case of emergency. to compile a list of their interests and skills, like a mini CV, so they can be We are continuously looking to matched to a suitable project. improve the service. The next area will be mobile IT solutions, which will Care close to home allow nurses to connect to electronic patient records and video call other Our intermediate care team (ICT) professionals. Ultimately, effective and prevents avoidable admissions to hospital efficient care close to home is better by supporting people within their own for our patients and their recovery. homes. They help patients who are well enough to be discharged from hospital but may need rehabilitation, intravenous The future medication or health monitoring while I am extremely proud of the work we they recover at home. do and what we achieve at NHFT. Even in busy and challenging times we Previously, the service had a daily continue to find new ways to improve handover at 2 pm, which saw nurses the care we give, make the best use »KEY MESSAGES of our resources and flourish as an organisation. » A community and mental health trust focused on providing integrated quality care with compassion We have built an organisation with » We strive to improve patient outcomes and experiences of the NHS by a strong foundation, but there are providing innovative care at the forefront of clinical and technological always opportunities to listen, learn and advances innovate. I look forward to the future with enthusiasm and conviction – a future » We are proud of and have confidence in our staff to provide quality determined by care with compassion. care that has the patient at the heart of all we do

32 | NORTHAMPTONSHIRE HEALTHCARE NHS FOUNDATION TRUST HEALTHCARE EDITION East and North Hertfordshire Clinical Commissioning Group

The East and North Hertfordshire Clinical Commissioning Group Governing Body Dr Hari Pathmanathan, Chair, East and North Hertfordshire Clinical Commissioning Group ealthcare faces what my local newspaper recently described as a ‘ticking grey time bomb’. The journalist was, of Hcourse, referring to our ageing patient population – a demographic challenge of huge proportions, which will require nerves of steel to defuse. The number of elderly residents in ABOUT EAST AND NORTH east and north Hertfordshire is set to increase by 22% between HERTFORDSHIRE CCG 2011 and 2021. People are living on well into their eighties and nineties, with all the accompanying health challenges that old » Designs and buys health services for over half a million age inevitably brings. people, and monitors the quality and effectiveness of those services Patients in Hertfordshire are relatively well informed, well cared for and articulate. They value their health and they value GP services. As a GP partner in a generally » Annual budget £630 million prosperous home county, it would be easy to assume that everything in the garden is rosy. However, only truly radical change can secure the future of the local health services that patients rely on, because ageing patients are only half of the story.

As our patient cohort ages and grows, our GP population is approaching retirement, and newly qualified doctors are not stepping forward to take their place. The demand for primary healthcare services is outstripping supply, and my clinical colleagues are running ever faster just to stand still. As the baby-boomer generation of patients hits retirement, they are justifiably bringing their high expectations of public services with them. The retired ranks of the generation that doesn’t want to ‘bother’ the doctor are being swelled by their sons and daughters who are used to being listened to and catered for – with round-the-clock services accessible on demand.

I chair East and North Hertfordshire Clinical Commissioning Group (CCG), which commissions health services for 580,000 people in the eastern half of the county

E AST AND NORTH HERTFORDSHIRE CLINICAL COMMISSIONING GROUP | 33 T LAHE PAR I MENTARY REVIEW Highlighting best practice

of Hertfordshire. It is up to me and my in part by elderly patients losing the governing-body colleagues to act now confidence to return home after a spell to ensure that local health services in hospital. Through our shared will to survive to serve our patients into the tackle this issue, we began our ‘hospital future. Together with our partners in at home’ scheme. Now, when a GP in social care and the organisations that a HomeFirst area is concerned that a deliver health services on our behalf, patient is not well enough to stay at we are developing and implementing home unsupported, a multidisciplinary We are a far-reaching strategy for out-of- rapid-response team arrives within developing and hospital health services. We need an 2 hours to put in place a package of approach that satisfies the changing medical and practical measures that

“ implementing needs and demands of our patients meet that patient’s needs. and encourages the brightest and best

a far-reaching young doctors, nurses, therapists and HomeFirst teams bring together care workers to serve our communities. social-care staff, community nurses, strategy for“ therapists and clinicians, preventing out-of-hospital In the 2 years since our CCG came into hundreds of unnecessary hospital existence, our clinician-led board has admissions a year in two of our six health already used its collective experience ‘localities’. As we scale up the scheme services and the insight of our patients and to cover our whole area, the learning carers to introduce new models of from the initial implementation is being care. Our HomeFirst ‘hospital at home’ incorporated in the model. Specialists scheme is a good example of this. in elderly care and mental health will join the next ‘hospital at home’ teams, as it has become clear that our frail The HomeFirst model elderly patients in particular will really Elderly and frail patients can find being benefit from their expertise. admitted to hospital a disorientating experience that separates them from For an increasing number of their families and friends. Our partners Hertfordshire’s elderly residents, ‘home’ at Hertfordshire County Council face is a care home or nursing home. We rising residential-care bills, generated are now implementing a care home A patient is visited at home by improvement programme that will Harri Ramchurn, a community nurse based in Waltham Cross bring the HomeFirst focus on preventing unnecessary hospital admissions to this vulnerable group. Through our work with care home provider organisations and local authority home-care commissioners, patients will benefit from regular visits from a dedicated GP practice, better trained staff, patient record-sharing agreements and expert medication reviews.

This blurring of the traditional boundaries between hospital and home care through bringing hospital consultants into the community points the way to a more flexible future for health care in Hertfordshire. Patients will not be the only beneficiaries of our approach – clinicians should benefit too. Our GP practices are

34 | E AST AND NORTH HERTFORDSHIRE CL INICAL COMMISSIONING GROUP HEALTHCARE EDITION understaffed – with 75 full-time vacancies across our 60 practices. By 2020 we will need a further 126 full-time GPs just to keep up with current demand – but young doctors just aren’t choosing general practice. Whether it is a reluctance to saddle themselves with the cost of buying into a partnership or the perceived lack of career opportunities, there is a growing recruitment crisis that won’t just go away. General practice is being hamstrung by the business model previous generations of clinicians fought to preserve.

I strongly believe that we need to offer The New QEII Hospital in new employment models to bring in Welwyn Garden City a talented new generation of GPs and practice nurses. Now that CCGs are, for patient care. Commissioned after in many cases, directly commissioning a lengthy public engagement and GP services in conjunction with consultation process, the £30 million NHS England, as well as community community hospital is a modern, healthcare and hospital treatment, sustainable building equipped with we have an opportunity to create new diagnostic equipment. There is a 24-hour Urgent Care Centre treating stimulating and attractive career paths. minor illness and injury, and bright, Salaried GPs could, in future, be light treatment rooms designed to be employed directly by CCGs, hospitals used and shared flexibly by all of the or other providers, splitting their organisations that care for our patients. »CASE STUDY working sessions between general There are no inpatient beds at the New 86-year-old Ernest Havis practice with a senior mentor, hospital- QEII because, whenever it is right for from Cheshunt was one of or community-based sessions, and their treatment and recovery, we want the first patients to benefit commissioning and education. Over the majority of patients to be cared from HomeFirst: the course of a 3-year programme for where they live, through schemes this approach would nurture a new including HomeFirst and our enhanced ‘I used to have to go into generation of doctors with a skill mix care-home project. When a medical hospital for physio to help that would provide tangible benefits emergency or treatment requires an me to get mobility back to patients. Moreover, they would be overnight stay, the New QEII’s sister into my legs and arms. relieved of the traditional GP partner’s hospital in nearby Stevenage is the Through HomeFirst, the burden of running a small business. local centre for specialist and inpatient physiotherapist came to As a doctor, I am concerned about the care. my house and showed me amount of time my practice colleagues exercises I can do at home, As we look to create healthcare and I spend discussing issues relating to and the nurse visited to systems fit for the future, the our ageing buildings, rather than our check my blood pressure governing bodies of CCGs should elderly and frail patients. and my pulse. I have a lot be ambitious for their patients. As of local friends, and if I stay The provision and location of accessible clinical leaders, we must look beyond at home then I can keep premises in our communities is, of perceived wisdom and organisational in touch with them. It also course, a legitimate concern. The boundaries to find flexible and means that my wife Audrey New QEII Hospital in Welwyn Garden pragmatic solutions to the challenges doesn’t need to travel in and City, which opened in May, says a lot that face our patients and the NHS. out of hospital to visit me.’ about our organisation and our vision

E AST AND NORTH HERTFORDSHIRE CLINICAL COMMISSIONING GROUP | 35 T LAHE PAR I MENTARY REVIEW Highlighting best practice Luton & Dunstable University Hospital Foundation Trust

Luton & Dunstable University Hospital Emergency Department Mr David Kirby, Clinical Director in Emergency Medicine t the very heart of the Luton & Dunstable University Hospital Foundation Trust (L&D) is a culture based on the Aconviction that to deliver the best clinical outcomes, the safest care and the highest standards of quality, ‘learning’ and ABOUT LUTON & DUNSTABLE UNIVERSITY HOSPITAL ‘teamwork’ are indispensable. The commitment to learning and FOUNDATION TRUST teamwork has shown results. Since 2012 the organisation has

Provides a comprehensive range consistently met or exceeded national quality and performance of emergency and elective standards, while continuing to make financial surpluses. medical and surgical services for adults and children, alongside an increasing range of more Throughout the Hospital there is a spirit of clinical ambition. As specialities grow they specialist care attract highly competent staff keen to implement the latest advances in medicine, and provide 7-day services, diagnostics at the time of need and the shortest possible Activity 2014–2015 inpatient admissions. Importantly, the organisation has also demonstrated an ability to » Elective day cases: 23,532 ‘turn around’ poorly performing services and to maintain improvement. During recent » Non-elective day cases: 35,569 years the L&D has been recognised for excellence in emergency medicine. » Inpatients: 44,597 Urgent and emergency care provision has dominated the media’s coverage of the NHS over the past 12 months. Headlines have described a system at the point of » Outpatients: 267,798 collapse due, variously, to relentless increases in demand, an ageing population, » Babies delivered: 5,236 changes to GP contracts, or mismanagement at both a national and local level. » Emergency Department While it is undeniable that the system is under immense pressure, at the L&D a attendances: 127,465 focused, long-term urgent and emergency care strategy has led to consistent performance against the national A&E clinical indicators, including the achievement » Inpatient beds: 660 of the 4-hour emergency department target, in every single week since February » Employees: 3,992 2012. The trust’s focus on achieving the 4-hour target is founded on the belief that the measure is a fundamental patient safety indicator as well as a regulatory

36 | LU TON & DUNSTABLE UNIVERSITY HOSPITAL FOUNDATION TRUST HEALTHCARE EDITION requirement. Crowded emergency ‘front door’ model of the hospital had departments lead to poor clinical to change. Working with local primary outcomes, and it is essential to the care trusts a new co-located Urgent trust that the safety of our patients GP Clinic was piloted in 2012, with should not be compromised by patients being diverted away from the systemic failures. emergency department by experienced nurses using simple clinical guidelines Delivery of these standards has in combination with their expert clinical required a whole-system approach, judgement. The pilot’s success led to The trust’s focus bringing together the local health the continued commissioning of the economy’s health and social care service. In 2014–2015, 36,000 patients on achieving the stakeholders with a view to addressing were diverted away from the emergency the issues throughout the urgent and “ 4-hour target department, ensuring the sickest emergency care system. patients received the timely care they is founded on The journey began in 2011 with the required. Further development of the the belief that setting out of the emergency department model is planned for the coming years, team’s ambition to become the best focusing on the complete integration the measure is performing emergency department, of the Urgent GP Clinic within the in terms of clinical outcomes and footprint of the emergency department, a fundamental operational performance, in the east ensuring patients are cared for in the patient safety “ of England. The commitment of the most appropriate setting and that the trust board to support this ambition has highest standards of clinical governance indicator as well been demonstrated with continuous can be met. as a regulatory investment. In 2011 the existing department was refurbished to provide a Changing population requirement modern and functional unit that allowed The advance of medical research and the emergency department team to work technology, coupled with changes more efficiently, including, for the first in cultural behaviours, has led to the time at the L&D, a dedicated paediatric population accessing healthcare in emergency department. In 2014 the unit very different ways from the traditional was developed further with the opening model. With people living longer, the of five new high-dependency cubicles. health and social care of our elderly With the environmental problems population has never posed more of a addressed the team could then focus Technology plays a significant on identifying and dealing with other role in supporting the patient pathway barriers to delivering the standards of care demanded. Understanding that there is no panacea that rehabilitates an urgent care system’s problems and that the problems the system faces can change from year to year, a systematic approach has been adopted that identifies each issue as it arises and tailors a solution to fit the specific needs.

Increase in demand In 2011–2012, 79,000 patients came through the department’s front doors. In 2014–2015 the number was 128,000 – a 60% increase in just 3 years. In order to cope with activity on this scale, the

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one part of the system can lead to significant consequences that often manifest at the system’s point of easiest access – the emergency department. In order to respond to these fluctuations, the L&D has developed a set of local triggers that give advance warning of impending problems, be that a surge in emergency department activity in the past hour or a marginal increase in delayed transfers of care. Hourly monitoring of a range of indicators allows corrective action to be taken at a time when small changes in process can still be effective, rather than allowing situations to develop Senior clinical decision-making that cannot be easily or quickly resolved. To keep on top of the daily challenge. In Luton and Dunstable, groups, from multiple organisations, workload, the trust has developed a however, a younger than average have to work together in what can 24/7 control room, co-located with population, with a higher than average often be stressful environments. Within the emergency department. Staffed birth rate, has led to the greatest the emergency department this has by senior nurses and managers, increase in attendance coming from meant the development of a cohesive with information being fed in from children and young adults. In order to triumvirate of medical, nursing and all areas within the hospital, the manage the ever-changing volumes management staff, all working to control room acts as an operational of activity and case mix of patients, common goals with joint accountability hub from which all trust activity is the staffing of the department is and responsibility for every aspect managed. Proactive monitoring relies under constant review. Over the past of the unit’s performance. Across on ‘live’ information. The trust’s IT 5 years the consultant workforce has the whole system it has also meant strategy acknowledges this and the grown from three to ten whole-time multidisciplinary working with our aim is to develop an IT architecture equivalents, providing senior leadership specialty partners within the hospital that is seamless both within the on the shopfloor from 8 am to and also with external agencies, hospital and across the health midnight, 7 days a week. The number including pre-hospital, primary and economy. As activity changes, robust of paediatric nurses has also increased. community care, psychiatry and social data can then be used to modify While plans are in place to recruit care, to ensure a joined up system that individual triggers, to ensure they further consultants in emergency is able to respond appropriately to remain relevant. medicine, the ambition now is to any patient that presents at hospital. use our staff in a more efficient way, The integration of services is still in its Despite the department’s successes without increasing their numbers. infancy, however, and over the coming over the past 4 years, the ambition Through lean working, reducing years the ambition is to dissolve is to develop even further, so that duplication of work and redesigning existing organisational boundaries the L&D can position itself as the processes within the emergency so that the whole health and care region’s integrated major emergency department, the aim is to ensure staff economy can respond as a single entity centre, bringing together primary, are free to focus on using their time as in the ever-changing landscape. secondary, community and social care productively as possible. in a coordinated way that allows the whole urgent-care system to be as Identifying problems before efficient and effective as possible while Working across specialty they occur maintaining the highest standards of boundaries Emergency departments can be patient safety and experience for our For a healthcare system to function unpredictable. Sudden surges in ever-increasing population. effectively, different professional demand or the loss of capacity in

38 | LU TON & DUNSTABLE UNIVERSITY HOSPITAL FOUNDATION TRUST HEALTHCARE EDITION Queen Victoria Hospital NHS Foundation Trust

QVH provides highly specialist reconstructive surgery, plastics and burns care

Richard Tyler, Chief Executive ueen Victoria Hospital NHS Foundation Trust (QVH) operates a well-established ‘hub-and-spoke’ model. QThis makes it easier for more patients to access QVH’s specialist care and ensures the trust has a sustainable foundation for further developing its world-renowned services. QVH ABOUT QUEEN VICTORIA HOSPITAL NHS FOUNDATION continues to pioneer the hub-and-spoke approach, which TRUST reflects the focus on new organisational models in the Five Year » Reconstructive surgery, Forward View. burns care, sleep service, therapies and rehabilitation

The East Grinstead-based trust is a highly specialist provider of reconstructive » International reputation for surgery, plastics and burns care for patients across the South East. It has a innovative treatments well‑established network of 13 spoke sites providing clinics for maxillofacial (head, » Sees around 50,000 new neck, face and mouth) surgery, head and neck cancer, and plastic surgery, including patients each year post‑cancer breast reconstruction. » Excellent patient experience QVH consultant Mr Laurence Newman holds weekly maxillofacial clinics in Medway ratings and explains the spoke patient journey: ‘Typically, a patient will be referred to a QVH clinic at their local hospital by their GP or another consultant,’ he says. ‘They’ll » 13 spoke sites across the have any tests or scans locally and we offer day-case surgery at our spoke clinics, South East along with all follow-up.’ More complex operations are carried out at QVH’s suite of new theatres in East Grinstead, supported by specialist theatre staff and equipment, with specialist post-operative care on hand.

‘I firmly believe services should be delivered as locally as possible,’ says Laurence. ‘Our spokes are allowing us to care for more patients closer to home. But when it comes to their surgery, most patients are happy to travel to QVH because they understand they’re getting the most expert surgical care and we have a very good reputation.’

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» CHARACTERISTICS OF SUCCESSFUL SPOKE SERVICES

» Meaningful service-level agreements understood by staff » Robust performance and commercial data » Attractive workforce models that encourage excellence » Clear roles and responsibilities » Added value for patients

QVH achieved the highest score in the out, while maintaining our quality country for the overall experience of and our brand, means we can grow care in the most recent national NHS our business.’ inpatient survey. Its reputation, coupled with the local access offered by the The review has identified a number of spokes, is important in the success of characteristics of a successful spoke. the model with patients. Whatever the contractual model used, it needs to be underpinned by ‘There are a number of hospitals a mutually beneficial relationship with Anita Hazari, Consultant Plastic nearer to our home than QVH the host organisation. Surgeon but I can honestly say that it’s As well as enabling spoke hosts to well worth the drive to be treated offer a wider range of services to their there.’ (QVH patient) local populations, the clinics also offer For the trust itself, the model is at access to QVH expertise. ‘By being the heart of its strategy to ensure its there, we provide a support service to services remain sustainable. ‘To flourish the local consultants,’ explains QVH as a small specialist provider, we consultant Miss Anita Hazari, who need to reach out across the region,’ runs a weekly plastic surgery clinic at explains Dr Ian Francis, QVH’s Director Canterbury Hospital. ‘I’ll often be asked of Clinical Strategy, who has been to review patients by vascular surgeons leading a review of the trust’s hub or orthopaedics that have encountered and spoke model. ‘Taking our services complications. They know me and have my mobile number if they need QVH’s excellent reputation is an important part of the success of advice at any time.’ Ian adds: ‘Having the hub-and-spoke model that presence is good for the local hospital, good for their patients, and good for QVH because it can generate activity and referrals that we wouldn’t otherwise have.’

QVH is using the review as a basis for further developing the hub-and‑spoke model. ‘We know in essence the model works really well,’ says Richard Tyler, QVH Chief Executive. ‘It improves access to life-changing services that no one else provides, and it takes pressure off other hospitals. However, we know it has its challenges, so the review has been an opportunity to explore how it could be developed, particularly in light of the Dalton report.’

40 | QUEENI V CTORIA HOSPITAL NHS FOUNDATION TRUST HEALTHCARE EDITION

Sir David Dalton’s review of NHS they need us. They would also allow us provider models was published in to consolidate some of our spoke work At a time when December 2014. He noted that into a more efficient offering.’ providers too often seek to retain the smaller trusts At a time when smaller trusts are status quo at the expense of operating finding it increasingly difficult to make outside of traditional organisational “ are finding it the economies needed to meet current boundaries. The report recommends financial pressures, the approach offers increasingly that organisational models should sustainability. ‘Around two-thirds of develop to suit local circumstances, with difficult to make the income we receive from a spoke providers likely to operate more than

service covers the cost of delivering the economies one model across their service portfolio.

that service. The remaining income needed to meet QVH will continue to develop spoke comes back to QVH and enables us to work towards our ambitions for services to meet the needs of patients current financial“ and commissioners. It will be working the future,’ Richard says. ‘It means with its partners to ensure that spoke we can invest in services for the pressures, the services are based on clear, agreed local community while making our approach offers service-level agreements that define world‑leading expertise available to the responsibilities and benefits of the even more patients across the region.’ sustainability services and the added value that they offer to patients. » QVH SPOKE SITES DELIVER ‘We’re also considering the possibility of “super-spokes”, where we would In 2014–2015, QVH spoke sites delivered: be able to provide some of the more » over 28,500 outpatient appointments complex surgery that we currently only » 2,800 outpatient procedures do in East Grinstead,’ says Richard. ‘These would make the expert care and » 1,600 day surgery procedures. excellent patient experience that we offer This accounts for 15% of the trust’s outpatient activity and 15% of its at QVH more convenient and accessible day surgery work. to an even wider range of people when

QUEENI V CTORIA HOSPITAL NHS FOUNDATION TRUST | 41 T LAHE PAR I MENTARY REVIEW Highlighting best practice Dartford and Gravesham NHS Trust

Darent Valley Hospital, one of Dartford and Gravesham NHS Trust’s four sites Susan Acott, Chief Executive Officer artford and Gravesham NHS Trust has a unique opportunity to design health delivery from the bottom up. As part Dof the new garden city planned at Ebbsfleet we have a once in a lifetime opportunity to contribute to the design of new ABOUT DARTFORD AND clinical-delivery models with health and wellbeing at the fore. This GRAVESHAM NHS TRUST new conurbation has the capacity for up to 15,000 new homes, Dartford and Gravesham NHS the majority of which are being constructed over the next 5 years. Trust offers a comprehensive In addition to this substantial housing development, there are range of services to a growing advanced plans to build a major theme park next to Ebbsfleet. population of around 340,000 people across North Kent and South East London in Dartford, The modern Darent Valley Hospital sits next to these developments and is grounded Gravesham, Swanley and in the local community. Our ambition is to provide integrated and comprehensive Bexley. It will also serve the self-care that is financially sustainable. With our ageing population, we want to new garden city at Ebbsfleet. enable people to stay living in their communities as long as possible, ensuring they We provide services at Darent are self-reliant and are able to access health and social care advice and information Valley Hospital, Queen Mary’s as easily as possible; while ensuring that care, when needed, is provided in the Sidcup, Erith and District lowest intensity environment and as locally as possible. Hospital and our rehabilitation unit, Elm Court. The trust is passionate about the care our patients, their families and carers receive, and aims to provide care that exceeds their expectations at all levels. We are committed to providing the professional care and exceptional quality in all aspects of our services that patients, families and their carers expect. This commitment has been strengthened by engaging over 300 staff in developing a set of trust values.

These values are now being used to underpin staff behaviour and the trust’s future strategy and plans. A number of actions have already been taken to embed our

42 | D ARTFORD AND GRAVESHAM NHS TRUST HEALTHCARE EDITION

» OUR VALUES

» Care with compassion » Respect and dignity » Striving to excel » Professional standards » Working together

values with our workforce, including the introduction of patient experience workshops as part of induction and other training and communication events.

As with most acute district general hospitals we have to be prepared for the busy winter period, building on Providing care in patients’ homes – we want to provide our experience of managing increasing care in the lowest intensity admissions and delayed discharges. environment and as locally as The hospital helped develop, and now Another of the successes the trust has possible leads, an Integrated Discharge Team had in the last year is in improving the that works across the whole health and flow of patients through the Darent social care system. It coordinates care for Valley site. The tipping point for patients between different agencies and success was a targeted effort to get the organisations with the aim of ensuring right patient, in the right place, at the that care and treatment requirements right time. This was a multi-disciplinary are dealt with seamlessly and speedily. approach in which ward-round times were changed, specialist beds were Any patients at Darent Valley protected and closer working with Hospital who have completed their community and social care colleagues acute phase of care but still need was established. some rehabilitation, assessment or Recuperating at Elm Court – a more appropriate environment mobilisation, or who are waiting for for those who are ready to leave longer-term care arrangements to be hospital finalised, will recuperate in Elm Court at Priory Mews. The unit is based in the community, providing a more appropriate environment for those ready to leave hospital, and frees up much needed beds for those requiring acute surgical or medical admission to the hospital.

This unit and the Integrated Discharge Team have been our success stories over the year, and have helped us achieve the 4-hour A&E waiting time target and to be the best performing A&E in the country during the NHS’s highest week of A&E attendances during 2014.

D ARTFORD AND GRAVESHAM NHS TRUST | 43 T LAHE PAR I MENTARY REVIEW Highlighting best practice

The trust is active in the Twittersphere patients with neutropenic sepsis’, which and on social media, with an active was awarded to ground‑breaking Patients, Facebook page and Twitter account. and high-achieving clinical teams and visitors and Patients, visitors and carers are innovators. We were the number increasingly using social media as one NHS trust for staff engagement “ carers are a way of letting the organisation (according to Listening into Action) for know what is good, or not, about 2013–2014. increasingly their experience. The trust regularly This is only part of the engagement responds to tweets and has an active using social with our staff, as the whole organisation and growing following of both internal is geared towards doing positive things media as a way and external people. for them and has been an Investor in

of letting the Staff engagement and development is People for a number of years. a fundamental of the positive, friendly,

We are also actively involved in organisation caring and compassionate culture developing new models of care as that exists within our organisation. know what is “ part of the implementation of the Our people are highly engaged in the NHS’s Five Year Forward View. We good, or not, running of the trust and make a huge have submitted a shortlisted bid, contribution to service improvement about their working with our health and social care and patient safety. experience partners, to develop a more integrated We were winners of a patient safety care system for patients. award in 2014 for ‘timely treatment of

The A&E team at Darent Valley Hospital

44 | D ARTFORD AND GRAVESHAM NHS TRUST HEALTHCARE EDITION Bolton NHS Foundation Trust

Bolton NHS Foundation Trust

Dr Jackie Bene, CEO

n March 2012, a sudden financial crisis hit Bolton NHS Foundation Trust. It found itself in deficit by £1.9 million Iagainst a forecasted surplus of £1.7 million. A year later the deficit had deteriorated to £14.4 million. The trust was also failing on a number of key operational performance and quality ABOUT BOLTON NHS FOUNDATION TRUST targets, and subsequent investigation uncovered a number of serious financial and governance concerns. Bolton NHS Foundation Trust provides hospital and community services for a Monitor, the regulator for foundation trusts, found that the problems had arisen due to population of around 320,000 a failure of governance. In August 2012, Monitor decided that the trust was in breach and has an annual turnover of its authorisation, and appointed a new Chairman. Following this, a new executive of around £280 million. The team was appointed to tackle the problem. By March 2015 the trust had recovered its trust is one of three in Greater financial position to one of surplus, having delivered £40 million of savings. Manchester that provide high‑risk obstetric and tertiary As well as achieving financial recovery, the trust is now performing well on key neonatal care, and is has the operational and quality targets against a backdrop of a very positive staff survey in second busiest accident and late 2014. Virtually all the Monitor interventions have now been lifted. I attribute emergency department in the this tremendous turnaround to the sheer hard work and determination of the staff, area. The trust’s vision is to strong clinical engagement, vastly improved financial management and accountability, continue to provide excellent and the leadership skills of the newly appointed executive team and trust board. hospital and community services for the local health Bolton NHS Foundation Trust is a medium-sized district general hospital providing economy and specialist hospital and community services for a population of around 320,000 and has an annual women’s and children’s care turnover of around £280 million. It is also one of three specialist providers in Greater on a wider footprint. Manchester of high-risk obstetric and neonatal services. Before I became CEO I was the trust’s Medical Director, and have been a Consultant in Elderly and Acute Medicine at the trust since 1998. I feel there has always been a high level of clinical engagement

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an explanation, but were equally very supportive of finding rapid resolution. They were very receptive to the suggestion that they could play a vital role in the organisation’s recovery and were particularly keen to take some responsibility. A key early decision, therefore, was to engage the staff quickly in service line management.

There was also an immediate need to address the skills and governance in both the finance and wider management teams. This was done using a structured approach as part of the Finance Improvement Plan, which addressed competence and commitment Theatre care surgical staff throughout its deployment. A simple performance management framework that has served the organisation well over was put in place, establishing real the years, and was a crucial ingredient financial accountability. Within this

Only £1 million in the ability of the trust to recover framework was a focus on quality from what was a hugely unexpected and patient safety at all times. Once

of the deterioration in 2012. the frameworks were established and the tools in place, all the money was “ £15.8 million “ During the first 6 months of the devolved to the clinical divisions and saving has downturn there was widespread all the necessary information given to organisational bewilderment and front-line teams. Despite a tendency to come from confusion, with no early explanation want to focus on boosting income, a for the rapidly deteriorating financial significant amount of repeated savings bed closures deficit. The staff, and in particular the have been made in the clinical divisions. clinicians and consultant body, were These savings came from over 300 small quite rightly very vocal and demanded schemes, all requiring focus and close management to realise their full value. A member of the community Only £1 million of the £15.8 million intermediate care staff with a saving has come from bed closures. patient The equally strong focus on quality and safety, including investment in nursing staff, through 2014 was also a major contributory factor to success in the organisation. There has been considerable effort put into quality improvement and clinical leadership development, in addition to a complete review of the governance and risk framework led by myself alongside the nursing and medical directors. This strong clinical leadership and focus on patient safety and experience has breathed new life into the quality agenda at the trust, as demonstrated by significant improvements in

46 | BOL TON NHS FOUNDATION TRUST HEALTHCARE EDITION infection control, incident reporting, complaint management and mortality reduction.

So from a position of abject failure on many levels, resulting in widespread staff distress and low morale, the trust has been able to recover its credibility and reputation, giving it an important platform upon which to address the future challenges. The financial position is clearly very significant, and for a medium-sized NHS trust with little cash reserve the challenge ahead is great. Given that much of the organisation’s success has been driven through its front-line staff, a much improved staff Staff with a patient in the acute engagement rating in such a short space stroke care unit of time is hugely significant. I feel that this and the much refined performance, governance and financial frameworks Whatever the future holds and now in place give the trust its best whatever ‘form’ the trust takes, it chance of survival moving forward. will now be able to engage as an ‘equal partner’ in the sector, which In common with many other NHS is important for the local community. trusts of similar size up and down the The confidence gained by our staff country there is now a very real need to throughout this difficult journey and consider what ‘form’ the organisation the tools with which a highly engaged should take over the next few years. workforce can now operate will be The picture in Greater Manchester is as critical to the trust’s success in the complex. There is already a potential future as they have been in the past. reconfiguration of acute services underway, and recently the government announced devolution of, and a broader responsibility for, health and social care budgets (Devo Manchester). This A midwife with baby and mum will undoubtedly present challenge as well as opportunity. The trust is well placed, however, as a provider of community services to benefit from the integration agenda, and it already has a positive and developing relationship with the local council, which will be nurtured. The trust fully recognises the increasing importance of joining up pathways of care with local GPs, which will require even higher levels of clinical engagement from the trust’s clinical leaders and an increasing external focus. The fact that the trust is a provider of a specialist services for women and children is also a distinct advantage, and one upon which to build.

BOL TON NHS FOUNDATION TRUST | 47 Review of Parliament

Labour MPs rebel over welfare

The package of welfare measures and minimum wage increases at the heart of George Osborne’s budget created havoc on the Labour benches. For many Labour strategists, the perception that their party was soft on welfare was an important factor in their election defeat. But faced with the sweeping cuts proposed by the Chancellor, Labour MPs were unable to unite around their acting leader, Harriet Harman, who wanted to abstain on the second reading of the government’s Welfare Reform and Work Bill. This lowered the cap on The government’s post election Welfare how much a household can receive in will make the biggest difference to the Reform and Work Bill benefits and limited child tax credits to most disadvantaged children now and in caused dispute within two children per family – although it future.’ He visibly enjoyed the discomfort the Labour party would only begin to apply to children of Labour MPs. born after March 2017. For Labour, shadow work and pensions The former social security minister, minister Stephen Timms supported Helen Goodman, led the internal some sections of the Bill but criticised dissent with a ‘reasoned amendment’ the government for – as he saw to kill the Bill, which attracted the it – dropping the ambition to reduce signatures of 60 Labour MPs. That child poverty: ‘Instead of eliminating forced Harriet Harman to propose the scandal of child poverty, the Bill her own amendment setting out attempts to eliminate the term.’ which cuts Labour supported, but also seeking to stop the Bill. The other parties in the Commons opposed the Bill outright. The SNP’s In the ensuing Commons debate, the Hannah Bardell said it would push work and pensions secretary Iain Duncan children and families deeper into poverty, Smith said his Bill would target the ‘five and the Lib Dem Tim Farron, making his key pathways to poverty that affect Commons debut as party leader, said children’s life chances: worklessness, the government did not have to take educational attainment, drug and £12 billion from the poorest families in alcohol addiction, family breakdown the country, but chose to do so. and problem debt. The Bill will remove the existing measures and targets in the Another important voice was that Child Poverty Act 2010 and introduce of the Labour chair of the Work and a new duty to report on worklessness Pensions Select Committee, Frank Field. and educational attainment … Our new He said Labour should defend the three approach will drive real action, which million ‘strivers’ who depended on

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difficulty for Harriet Harman, said the government had no mandate for the Bill: ‘Throughout the election the Tories refused to say how they were going to save £12 billion from the welfare bill, because they knew that the measures would be unpopular and it would hit them in the ballot box.’

Another Labour MP, John McDonnell, was more graphic: ‘I would swim through vomit to vote against the Bill … We hear lots about how high the welfare bill is, but let us understand why that is the A split of 48 MPs caused Labour’s amendment to case. The housing benefit bill is so high the welfare bill to lose by in-work benefits. They were ‘walloped’, because for generations we have failed 208 to 308 votes he said, with many becoming £1,000 a to build council houses, we have failed to year or more worse off. control rents and we have done nothing about the 300,000 properties that stand But there was strong support from the empty in this country. Tax credits are so Conservative side, where influential high because pay is so low. The reason backbencher David Burrowes was why pay is so low is that employers have jeered when he claimed membership of exploited workers and we have removed ‘the workers and one nation party.’ He the trade union rights that enabled said the Bill could also be described as people to be protected at work.’ the ‘catch you when you fall Bill’ or the ‘lift you when you can rise Bill’. By signalling a major change in welfare policy, the Bill had exposed a serious Helen Goodman, whose rebel rift in Labour’s ranks. In the end, 48 amendment had caused such Labour MPs voted against it.

English votes for English laws

The Scottish independence referendum 300-year-old union of England and was a near-death experience for the Scotland – and after a poll showing Scotland voted to stay in the UK after voters the ‘yes’ side was in the lead, the rejected independence main party leaders had issued ‘the vow’, a promise of extensive further devolution. But on the morning after the referendum result, David Cameron had also promised to address the English question – the growing resentment at an asymmetric constitutional settlement that allows Scottish MPs to vote on English issues but does not allow the reverse.

The ramifications of this issue, and the prospect of a minority Labour government sustained by the votes of

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SNP MPs, became one of the dominant themes of the 2015 general election. And the issue was previewed when the Commons debated a government document – a command paper – setting out the options for EVEL, or ‘English votes for English laws’.

The options included a total bar on Scottish MPs voting on English and Welsh legislation, allowing English MPs a greater say during the early stages of consideration, and giving English MPs an effective veto at the committee stage of a Bill, and an English Grand Committee SNP and Lib Dem MPs of the Commons, again with a veto over warned that the proposal England-only legislation. for ‘English votes for ifs, no buts, no committee limitations, no English laws’ risked turning To the regret of the leader of the tricks. Give us what we want … Will he the Commons into a quasi‑English parliament Commons William Hague, Labour now join me in speaking for England?’ had not engaged in the debate. ‘It is an issue that too many people have The Conservative 2015 manifesto avoided for too long and it can no included a detailed scheme for those longer be put aside,’ he said. standing order changes, to allow an effective English veto on legislation – Labour’s shadow justice secretary Sadiq and those proposals were confirmed Khan warned against hasty action: in July. But when the former Scottish ‘what we must not do, only months secretary Alistair Carmichael, a after the Scottish people voted to Liberal Democrat, employed a rarely keep our kingdom united, is allow the used procedural device to secure an division of our country by the back emergency debate on the proposals on door. Nothing we do should jeopardise 7 July, it became clear that a number the future of the Union … uniting our of key Conservative backbenchers were country is more important than uniting deeply troubled by the implications for the Tory party.’ That was a swipe at the future of the UK. David Cameron, who faced criticism Sadiq Khan, Labour’s shadow justice secretary within his party for making too many Mr Carmichael said the proposal was concessions to Scottish demands – it one no Unionist should advance: ‘It is had become increasingly clear that many perfectly understandable for people in of his troops would not support the England to identify a national interest promised further devolution for Scotland in response to the mood of Scottish without action on the English question. nationalism forming north of the border, but the answer is not to meet One of the key advocates of EVEL it with more nationalism. The answer was the former cabinet minister John is, I suggest a proper federal structure.’ Redwood, who argued that major He was interrupted by the Conservative constitutional legislation was not needed, Andrew Bridgen, who accused him and that it could be brought in via a of ‘wanting to have his porridge and simple change to the standing orders eat it’. Mr Carmichael insisted he of the House of Commons, on a single understood that there was a problem: vote. He challenged Mr Hague: ‘England he simply didn’t believe that the expects English votes for English issues. answer was ‘trashing the Union and We expect simplicity and justice now, no the United Kingdom parliament’.

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So, he warned, preventing Scottish MPs from voting on those issues would hand the Scottish nationalists a grievance they would exploit: ‘Of course the SNP wants independence [cheers from the SNP benches] but why are we making it easier for them? …Why are we giving this gift to the SNP?’

For the SNP, Pete Wishart drew a lesson from history: ‘What we are doing is quite extraordinary. We Sir Edward Leigh warned have not done anything like this for that Scotland must be handed ‘home rule’ to centuries. It is of historical significance stop a ‘toxic mixture’ of because it is of such constitutional circumstances destroying importance … Back in the days of the union Gladstone, this was being done in The new leader of the Commons, Chris order to curtail the voting rights of Grayling, insisted the central issue Irish MPs, and history is able to judge remained one of fairness: ‘If members how successful that was in maintaining of the Scottish parliament are in future the Union.’ A point that attracted the to decide a Scottish rate of income support of the Democratic Unionist tax … is it actually unfair that English Ian Paisley, who warned: ‘no-one can members of parliament, or English predict the crisis that could engulf and Welsh MPs, or English, Welsh and Scotland, England, Wales and Northern Northern Ireland MPs have the decisive Ireland as a result of what is happening say over tax rates that affect their here’. This was a crucial intervention constituencies?’ because it made clear that the government could not rely on the DUP But perhaps the most influential to bolster its slim Commons majority. contribution came from the Conservative ex-minister Sir Edward Faced with evidence that a small Leigh, who crystallised the anxieties of but influential band of its own MPs some of his colleagues. He said votes would not support its proposals, the on many ostensibly English issues government retreated and promised had knock-on financial consequences a consultative debate, after which a for Scotland (known as ‘Barnett refined version of the standing order consequentials’ in parliamentary jargon). changes will be voted on in the autumn.

Commons meltdown over the non-vote on the European Arrest Warrant

The issue of shared justice powers opposition of Eurosceptics and civil within the EU was one of the most libertarians. Britain had negotiated a sensitive of the 2014–2015 Parliament – blanket opt-out from EU justice and and, in particular the European Arrest policing cooperation, but the deal also Warrant (EAW), seen as a vehicle for allowed the UK to opt back in to those arbitrary arrest in Britain, at the behest powers where the government wanted of foreign courts, had attracted the to work with other member states. And

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backbench critics of the EAW had been promised there would be a full-dress Commons debate on any UK opt-in.

But when that long-awaited debate came, it produced angry and sometimes farcical Commons scenes, when the Speaker ruled that the motion did not include the warrant at all. The home secretary Theresa May argued that the vote could be taken as ‘indicative’ of Commons consent for the EAW. She was rebuked by the Speaker, who said the government was ‘trying to slip things through by some sort of artifice’ and that the public was ‘contemptuous’ David Cameron has suggested MPs should of such conduct. the debate – which led to a rebellion by ‘move on’ after the government’s decision not The shadow home secretary Yvette around 30 government backbenchers, to hold a parliamentary Cooper piled in, mocking the and the government motion was vote on rejoining the government’s tactics, as a ‘shambles’ only just carried, by nine votes. In the European arrest warrant and ‘complete chaos’ – but it was debate proper, Theresa May warned the language used by a succession of that if the powers were not agreed, furious backbench Conservatives that there would be an ‘operational gap’ on would set alarm bells ringing in the issues like extradition and international government whips’ office. The former prisoner transfer, which would create minister Sir Edward Leigh asked simply, real problems for law enforcement. but devastatingly, ‘What are we voting on?’ Maastricht veteran Sir Bill Cash said Yvette Cooper praised Theresa May for the debate was ‘tainted with chicanery’. making an excellent defence of powers Sir Richard Shepherd said the manoeuvre that were not referred to on the order brought the Commons into disrepute. paper: ‘given that there is a majority Jacob Rees-Mogg dismissed it as ‘an in the House for the European Arrest outrageous abuse of parliamentary Warrant, why on earth are we not procedure … fundamentally underhand’. voting for it. Why the sophistry, why the games?’ And she tried an unusual There were repeated calls for the procedural manoeuvre, by moving that home secretary to explain herself, and the question ‘be not now put.’ when she rose to speak she showed considerable steadiness under fire That was defeated and – with absent as she insisted that the EAW did not Conservatives answering an urgent require a vote because it was already on summons to return to Westminster the statute book; the motion referred (the Prime Minister went through the to the measures that did need to be division lobbies in white tie, having transposed into British law. ‘However, been called back from a Mansion the government are clear that the vote House banquet) – the criminal justice that will take place on the regulations measures were approved by 464 will be the vote that determines whether votes to 38. But the whole event left or not we opt into these measures.’ Conservative Eurosceptics deeply suspicious of their own leadership – a Labour, unusually, forced a vote on the mood that persisted into the new motion, setting out the timetable for 2015 parliament.

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Bercow ambush

Only if there is significant dissent is an actual division held, and in those circumstances the way each MP votes is a matter of record.

That, of course, is a significant deterrent to voting against a Speaker – MPs who support an attempt at removal, and fail, could face retaliation – not being called to speak, or only being called very late, for example. So, there was a democratic case for changing the rules – but this manoeuvre smacked of a coup against a Speaker who had been a thorn in William Hague wanted a secret ballot to decide the ministerial sides, and who had made Speaker’s future after the It was a cunning plan, a last minute plenty of enemies on the Tory benches election ambush, intended to make Speaker with his withering put-downs. More Bercow more vulnerable to removal than that, Bercow’s procedural rulings at the start of the 2015 Parliament. It had frequently displeased ministers – backfired badly. and might present them with even greater problems in the event of a The final pre-election week of any hung parliament. parliament is usually devoted to legislative loose ends, resolving detailed Conservative MPs had been kept disagreements between the Commons in Westminster for a party briefing. and the Lords about Bills still in the However, many Labour MPs had legislative sausage machine. This already left to start campaigning: if often involves motions being tabled the rule change was to be blocked, and debates being scheduled at short they had to get back. So, to buy time, notice – and so few eyebrows were the Speaker allowed three urgent raised when ministers pushed through questions, using up a couple of a procedural motion allowing them hours before the house reached the to put new business before MPs, at government motion. short notice. By that time, the Labour benches had But in the early evening of the filled up. William Hague was given penultimate day of the parliament, a rough ride as he argued that the the leader of the Commons, William rule change was overdue, and that Hague, visited the Speaker’s office the government had simply seen a to inform John Bercow that the good moment to give MPs a chance government intended to use those to debate it. He was supported powers to debate changing the way by Conservative MPs like Michael that the Speaker was re-elected at Fabricant – a strong critic of the the start of a new parliament. The Speaker, who invited him to ‘pay current procedure is for MPs to shout tribute to Mr Speaker who, on 20 July ‘aye’ or ‘no’ to the motion that the 2000 and again on 23 April 2009, incumbent Speaker resume the chair. advocated the need for secret ballots to

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stop government whips “browbeating” recounted how he’d attended end-of- MPs as to the way they might vote’. term parties and farewell drinks where there had been plenty of opportunity But Mr Hague must have been to tell him what was planned. wounded by the furious response from his Labour shadow, Angela Eagle, His peroration – delivered with who said the leader of the House was considerable emotion – was supposed to defend MPs’ rights: ‘I am devastating: ‘I have been played as sorry to say that by supporting this a fool. When I go home tonight, I grubby little plot against the Speaker will look in the mirror and see an on his last day as a parliamentarian, honourable fool looking back at me. I the leader of the House has failed would much rather be an honourable in his duty.’ Other MPs used fool, in this and any other matter, phrases like ‘stitch up’ and ‘grubby than a clever man.’ For the only time schoolboy intriguing’. in a difficult debate, William Hague’s composure cracked. Many Conservative As a noisy, angry hour of debate MPs were tearful. Labour MPs delivered continued, the killer blow came from an unprecedented standing ovation. In a Conservative, Charles Walker, an that moment the motion was clearly ally of the Speaker and member of lost – and Charles Walker became the the powerful executive of the 1922 likely successor to Mr Bercow. Committee, which represents Tory backbenchers. Crucially, he also And the sequel, when the Commons chaired the Commons Procedure met, after the May 2015 General Committee. The anger felt across the Election, was that the new chamber seemed to take form around Conservative government did not him as he complained that he was not orchestrate a challenge to the Speaker. consulted about a debate on one of Mr Bercow was re-elected with no his committee’s proposals – and he opposition at all.

Assisted Dying Bill

Attempts to change the law to allow terminally ill people to end their lives have cropped up regularly in the House of Lords in recent years – but the latest, the Assisted Dying Bill, proposed by a Labour peer and former Lord Chancellor, Lord Falconer, has proved the most serious yet. Private members’ Bills in the Lords seldom have much realistic prospect of becoming law, but this one produced a series of passionate and emotional debates.

Some of the most striking speeches Rule changes that would came during detailed debate – when give terminally ill patients the crossbench or independent peer was about aiding and abetting suicide, the right to die was Lady O’Neill tried to change its title and just as truth in advertising was rejected by the House of Commons to the Assisted Suicide Bill. She said it essential, so was truth in legislation.

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He thought the latter word was inappropriate to describe the rational choice of a mentally competent, terminally ill person seeking a dignified, peaceful death.

The Conservative veteran Lord Tebbit produced a copy of the Oxford English Dictionary and quoted the definition it gave: ‘“Suicide, the act of taking one’s own life – self murder”. Can we settle the matter now?’ Another Conservative, Lord Dobbs, retorted that Baroness Campbell of to end one’s life in a process involving Surbiton doctors, nurses and a judge was not She was supported by the Labour peer killing oneself. Lord Brennan – who said the language had to be brutally clear, and the clearer The most powerful attack came from the law the better the decisions people the disability campaigner Baroness would make. Campbell of Surbiton – who has A powerful riposte came from spinal muscular atrophy. Speaking the Labour peer Lord Cashman, from her wheelchair, she said that who described how his partner of like many people with disabilities 31 years had died of cancer. His voice she had experienced long periods of shaking with emotion, he said the depression, ‘but then things could circumstances of his loss shed some get better. When you, and if you, get light on the question – in his distress through that period … If in my case a he had wanted to commit suicide; his new ventilation system is developed, terminally ill partner had needed to you get better again. Maybe you have have his death accelerated. That was a week, or a month, or as in my case an important distinction. another 2 years. But during that weary low time when everyone is expecting The crossbencher Lord Pannick, an that this is the time that you are going eminent human rights lawyer, said to die, you could easily take advantage the idea that the public would not of an assisted dying exit.’ understand the Bill’s terminology was simply fanciful. But the Labour peer The House listened in utter silence and doctor Lord Winston disagreed – as she said she’d taken important elderly, confused, angry, distressed and decisions in those low periods. She perhaps even deranged patients who had not taken a pension because she arrived in hospital needed as much had always expected to die – and clarity as possible, he said. her request that peers remember that when she asked for a free lunch Lord Deben, the former Conservative produced a muted, rueful gulp, rather cabinet minister John Gummer, said than a giggle from peers. the Bill’s terminology should be stark, not soft – and the hearer needed to But the House voted to reject both hear the word ‘suicide’, not ‘assisted the attempt to change the title of dying’. But Lord Low, vice president the Bill and another amendment of the Royal National Institute of the for more restrictive rules on assisted Blind, suggested the real aim of the dying. And both votes underlined the amendment was to give assisted strong support it has now built up in dying the same stigma as suicide. the Lords. In the end, the Bill ran out

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of debating time, but its supporters produced a well-honed proposal that believe the extensive debate, and can be laid before the new parliament, changes, including the addition of for another attempt to write it into the judicial oversight to the process, have statute book.

The first Euro-rebellion of the 2015 parliament

The sequel to the 10 November 2014 row over the European Arrest Warrant was played out when the Commons came to debate the detail of the new Conservative government’s European Union Referendum Bill – when it became clear that many Eurosceptic Conservative backbenchers harboured deep suspicions of their own leadership.

The Bill would have allowed a vote on British membership to be held in parallel with the May 2016 elections – which will include the elections for the Scottish parliament and for the mayor and borough councils of London. And it also included a relaxation of the normal ‘purdah’ rules, which The European Union Referendum Bill caused restrict government activity that might to MPs, arguing that the purdah rules unease within the influence the result in the run-up to an could inhibit ministers in carrying out Conservative party election or referendum. the day-to-day business. Both of these could be – and were – But as the debate began, the former seen as an attempt to bias the SNP leader Alex Salmond, newly referendum in favour of the pro-EU returned to Westminster and now side: London and Scotland were seen his party’s foreign affairs spokesman, as pro-EU areas, where extra turn-out predicted a re-run of the events that he driven by their elections could produce believed had swung the 2014 Scottish additional votes for the ‘yes’ vote, and referendum against independence. ‘Let the relaxation of purdah would have us just assume that, to try to get the allowed, Eurosceptics feared, the whole “yes” result that the Prime Minister weight of the government machine to wishes, he needed a last-minute be thrown behind the ‘yes’ campaign. initiative. With no rules or restrictions Before the committee stage debate saying that new political initiatives began, the government had should not be made at governmental announced the referendum would level during the last 28 days of the not be held alongside the Scottish and campaign, what would stop the Prime London elections – which left purdah Minister doing a tour of the capitals as the main bone of contention. The of each of the governments across Europe minister David Lidington wrote Europe – suspending Question Time in

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the national parliament – and stop their Bill – the report stage – in September. flying as one to London to announce a Crucially, this was enough to ensure new commitment, a new undertaking, that Labour would not back rebel a new pledge, a new vow?’ Conservatives, allowing them to defeat the government. The Conservative and former defence secretary Liam Fox said it was But a rebel amendment from the ‘unseemly at best’ for the government veteran Eurosceptic Sir Bill Cash was to exempt itself from the normal pre- pushed to a vote – and, although it election restrictions – underlining that attracted only 27 Conservatives, no it was essential that the referendum one missed the significance of the process was seen as fair. He noted that moment. The Conservative Eurosceptics he had never, in 23 years in parliament, had demonstrated that they had defied his party whip, and he urged the the numbers and the will to defeat government not to force him to do so the government – if the other main on this Bill. opposition parties lined up alongside In response, Mr Lidington said them. So, the government avoided the government would exercise embarrassment only because Labour ‘restraint’ during the referendum did not take sides against it. With a campaign, and he promised to bring new Labour leader due to be elected in forward new amendments at the the autumn, ministers cannot rely on next stage of consideration of the similar support in future.

Danny Alexander’s last stand

Until 7 May, Danny Alexander was one to make clear that any ministerial of the four most powerful members statement had to be made on behalf of the coalition government. As of the whole government, not just one the Lib Dem’s man in the Treasury, component of it. He said it would be he sat on the Quad – the key unfair to the House for a minister to committee coordinating coalition use his privilege for party purposes, business, alongside David Cameron, and would put the chair in an George Osborne and Nick Clegg. awkward position. As the number two minister in the Treasury he was a co-author of the The chief secretary did attempt to final coalition budget, delivered on unveil an alternative economic vision 18 March by Chancellor George to that of his coalition partners: ‘Today Osborne. And the following day, with I set out a better economic plan for an election looming, and pressure Britain … based on values of fairness to put clear yellow water between as well as strength … [that] enables the Lib Dems and the Conservatives, our country to see light at the end of it fell to him to deliver a Commons the tunnel. It is not a rollercoaster ride, statement entitled ‘Fiscal responsibility but a steady path back to prosperity. and fairness’, which was billed as his It sticks to the path we have chosen in this government, rather than lurching Danny Alexander’s ‘Yellow party’s alternative budget. The attempt away from it by cutting too much or Budget’ was poorly was not a success. received borrowing too much.’ Essentially, he Even before Mr Alexander began, the unveiled the middle-way campaign Speaker, John Bercow, intervened, theme his party then used throughout

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the general election, but as a piece of There was no official Conservative parliamentary theatre the speech was response – but the backbencher Adam a failure. Afriyie pulled no punches: ‘I have to say that I am stunned by this statement … Mr Alexander was never a great This is the Westminster bubble at parliamentary orator, and was heckled its absolute worst, and it represents mercilessly by Labour MPs. At one everything that is wrong with politics point, the Labour front-bencher today. The Liberal Democrats have Andrew Gwynn threw a copy of the betrayed their voters, and their voters coalition budget book onto the table know it; their own candidates are in front of the chief secretary. He cut a now pretending to be independents; lonely figure at the Dispatch Box. Only a handful of Lib Dem MPs had turned and today’s display is an absolute out, and there were catcalls, jeers and betrayal of the role they have played shouts of ‘bye’ from Labour when his in government.’ leader, Nick Clegg, left the chamber A bruised Mr Alexander staggered to while Mr Alexander took questions. the end of his statement. Whatever the Labour’s Treasury spokesman Chris virtues of the policies he announced, Leslie was withering: ‘doesn’t he they did his party little good. Seven realise how two-faced he looks’. weeks later he was out of parliament, He complained that the statement a casualty of the SNP landslide in was an abuse of the procedures of Scotland, and his party was reduced to the Commons. a rump of just eight MPs.

A Queen’s Speech for working people from a One Nation Government

It was a tale of the unexpected; after an election campaign dominated by speculation over the possibility of a hung parliament, David Cameron’s Conservatives were now in government in their own right, with a modest but definite majority.

Their Queen’s Speech was the first purely Conservative programme for government since the distant days of John Major. Conservative MPs – whose number included plenty of new faces – were jubilant. Labour, which

almost till the last had expected to be The Queen outlined the in government, not opposition, was one-nation programme in crisis. The Liberal Democrats were of the first majority Conservative government reduced to a remnant, and the SNP of the chamber, where a lively border in two decades had taken over as the third party in dispute with Labour MPs became one the Commons, forming a confident, of the running themes of the early sometimes noisy phalanx in a corner weeks of the new parliament.

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high-skilled, long-term approach.’ She added that Labour was sympathetic to another key government policy, the idea of a new cap on annual household benefit payments.

On the constitution, she said any change to ‘English votes for English laws’ should be built on the ‘broadest possible consensus’. And she took a swipe at the SNP MPs, who all but wiped out Labour in their former Scottish heartland: ‘Of course the Scottish National party wants to break up the Union – it wants people to have The Prime Minister did to choose between being Scottish and not fail to notice the being British – but it would be utterly attendance of former SNP One sign of the change was the leader Alex Salmond in the irresponsible for the Prime Minister to Commons appearance of Labour’s Harriet Harman continue what he did so shamefully to speak for her party. Five years in the general election, which was to before, she had been acting leader set the English against the Scots … Let after the departure of Gordon Brown; us be in no doubt: the worst possible now she was filling in again, following outcome for Scotland would be the the resignation of Ed Miliband. SNP demanding full fiscal autonomy, which they know does not add up, and Recalling David Cameron’s admission a Tory Prime Minister giving it to them.’ that he would not seek a third term as Prime Minister, she remarked that David Cameron began his response they were both interim leaders – and with a barbed welcome for Harriet she promised the Conservatives that, Harman’s return as acting Labour with such a slender majority, they leader. And he noted the presence of would not have everything their way. the former Scottish first minister, Alex But there were ironic cheers from the Salmond, back on the SNP benches: ‘I government side as she confirmed that notice that he is now the foreign affairs Labour had dropped its opposition to spokesman for his party – for which I a referendum on the UK’s membership assume he speaks on issues relating to of the EU: ‘We believe that it will be England, Wales and Northern Ireland.’ better for Britain if we stay in the European Union. It is important for the He said the last parliament had future of this country, which is why 16- been about a ‘repair job’ on the UK and 17-year-olds should have the right economy, and this one would be about to vote in the referendum – it is their ‘renewal’. ‘This is the Queen’s Speech future, too.’ for working people, from a one nation government that will bring our country She warned that the economy, the together. We have a clear mandate constitution and public services from the British people, a long-term remained in a fragile state and that the economic plan that is working, a benefits of returning economic growth detailed and compelling manifesto, and were not being shared. ‘Britain cannot we will not waste a single moment in succeed with low-skilled, low-wage, getting on with the task,’ he said. insecure employment and a race to the bottom. The path to economic He announced that the government prosperity and recovery must involve a would legislate immediately for an EU

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membership referendum and would on the backbenches and wait quite a then embark on negotiations to reform while for the opportunity to deliver his Britain’s membership terms. And thoughts: ‘my party’s parliamentary while he welcomed Labour’s support presence may be much reduced in for the referendum, he noted: ‘If we size, but our mission is clearer than had listened to the Labour Party there ever. As we did in the coalition would be no renegotiation and there government, we will fight any attempt would be no referendum; there would to weaken the fundamental rights of be no choice.’ our citizens, whether those enshrined in the European Convention on Human As Deputy Prime Minister the Liberal Rights and the Human Rights Act, or Democrat leader Nick Clegg had sat those threatened by what sounds, from alongside David Cameron on the what I have heard today, to be a turbo- government front bench. But the charged snoopers’ charter.’ These election reduced his party to just themes were to unfold over the early eight MPs – that meant he had to sit weeks of the new parliament.

The new government’s first budget

It was George Osborne’s seventh budget, but his first completely Conservative one. And its sheer radical sweep left political parties and interest groups struggling to catch up.

The central element was a series of radical cuts to in-work tax credits, new restrictions on housing benefit and a reduction in the annual benefit cap to £23,000 a year per household in London and £20,000 in the rest of Britain. These measures were partially compensated for by a new £7.20 an hour national living wage for workers aged over 25 – an audacious raid on Labour’s election manifesto. It will come into force in April 2016 and rise to £9 Chancellor George an hour by 2020. As it was announced, Osborne’s focus was the work and pensions secretary Iain on cutting the welfare Duncan Smith could be seen punching bill by £12 billion and a low‑wage, high-tax, high-welfare the air in delight. And as Conservative boosting employment and economy to the higher wage, lower productivity in Britain MPs cheered, Mr Osborne repeated the tax, lower welfare country we intend announcement with theatrical flair – in to create’. He said the budget was the case Labour MPs hadn’t heard it the product of a ‘one nation’ government, first time. which had been entrusted by the The Chancellor hailed his proposals British people to rebuild the economy as a budget for working people ‘that on a stronger footing. And he pointed sets out a plan for Britain for the to the unfolding crisis in Greece as next 5 years to keep us moving from a warning of what could happen

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to abolish permanent non-domiciled tax status.

These measures would also allow the government to meet NATO’s annual defence spending target for member nations, of 2% of GDP. The threat that Britain might not meet that requirement had caused considerable disquiet on the Conservative benches – so the announcement was greeted with some pleasure there.

When the Chancellor sat down there were ecstatic cheers from Conservative MPs, who sensed that he had produced an economic package with real voter appeal, and one that wrong‑footed the opposition. Labour’s acting leader, Harriet Harman, promised to look constructively at The UK will have a proposals to cut welfare spending. surplus of £7 billion in But she warned that the new national 2019–2020, according to if this country failed to deal with projections from the Office living wage would not make up for the for Budget Responsibility its borrowing. cuts to tax credits, and many families would suffer as a result. And she One key announcement was that he added that the budget was ‘less about would continue to cut the deficit at the economic strategy and more about same pace seen in the last parliament – a pace that would see the UK move political tactics to help him move next to a surplus in the 2019–2020 financial door [from 11 Downing Street to the year. That promise was underpinned Prime Minister’s residence, No. 10]’. by a series of measures, including the The responses from a slightly punch- decision to restrict public sector pay drunk House of Commons reflected The Chancellor pledged rises to 1% per year, to replace student the need to fully digest an unusually to meet NATO’s target of maintenance grants with loans and complicated and far-reaching financial spending 2% of national income on defence every package. The newly re-elected chair year, up to 2020 of the Treasury Select Committee, the Conservative Andrew Tyrie, suggested that the recent electoral ‘bidding war’ had reduced the Chancellor’s room for manoeuvre, leaving too much of government spending ring-fenced from cuts, and he had not made his job any easier by tying his hands on tax, by legislating to prevent increases to the main taxes. But he thought this budget, the forthcoming spending announcements in the autumn statement and the budget next year would, taken together, provide a real opportunity to secure the economic revival of Britain.

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A less favourable assessment came from ‘lifestyle choice’ even if they were trying the SNP’s finance spokesman Stewart hard to find a job: ‘their lifestyle choice Hosie, who said that the Chancellor is to work, and they should not be had been wrong to suggest that people denigrated by someone who has never living on benefits were making a been short of a bob or two’.

MPs remember Charles Kennedy

For the victorious parties in the 2015 general election, the first few days of the parliament were celebratory – but the mood was punctured by news of the untimely death of a Commons star. The former Liberal Democrat leader Charles Kennedy had lost the highland seat he’d represented since 1983, and on Tuesday 2 June the morning bulletins carried the news that he’d been found dead at his home.

The Speaker led the ensuing Commons tribute session, his voice cracking with emotion: ‘Charles had Harriet Harman led the tributes in the Commons the rare ability to reach out to millions of his national influence – when his following the passing of of people of all political persuasions Charles Kennedy party opposed the 2004 Iraq invasion: and of none … who were untouched ‘He was right, but he never felt the by, and in many cases actively hostile need to denigrate those of us who to, politics. In this seminal sense, got it wrong … He was partisan, therefore, Charles was the boy next but he was still generous enough to door of British public life.’ admire people in other parties … I Mr Kennedy’s former wife, Sarah, remember when he first came to this and their 10-year-old son, Donald, House, aged only 23 – the golden were in the visitors’ gallery above the boy from the Highlands. He shone in government front bench. Donald’s this chamber.’ strong resemblance to his father Nick Clegg, the former Lib Dem added another layer of emotion to leader, who entered parliament an already highly charged occasion. when Mr Kennedy was still the party David Cameron spoke next, quoting leader, said Mr Kennedy was brave, Mr Kennedy on dealing with the yet vulnerable – brilliant, yet flawed. voters: ‘“the vast majority of people ‘There was a steely courage about think there’s a hell of a lot more him, most memorably on display to life than just politics,”’ … At his when he took the principled decision best he was the best that politics to oppose the Iraq war. Just because can be, and that is how we should remember him.’ that might seem now an obvious thing to have done, it most certainly was Labour’s acting leader Harriet Harman not at the time. Charles was often recalled what was probably the peak a lone voice in this House, standing

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up against a consensus on all sides leadership of the Liberal Democrats in favour of war. The fact that he when it was the third party in the was proved so spectacularly right House of Commons.’ is a tribute to his judgment and his Ian Blackford, who won the seat for intuitive common sense.’ the SNP, recalled him as a generous Angus Robertson, the Westminster opponent in his earlier, unsuccessful leader of the SNP, revealed a run against him: ‘I remember Charles surprising conversation: ‘While I and turning to me and consoling me. my colleagues were delighted that the Rather than putting the boot in … SNP won Ross, Skye and Lochaber, That was the mark of the man: I was saddened Charles Kennedy a decent, human man, who saw would no longer be in parliament. It the struggles that others were is a mark of the man that when I got going through.’ The University of Glasgow, in touch with him after the general But – as Charles Kennedy himself had where Mr Kennedy studied election, he readily agreed to meet and served as rector, acknowledged – he had a problem organised the memorial to up and share his experience of his with alcohol. A tragic illness, said pay tribute to their former another Liberal Democrat colleague, student Norman Lamb. ‘There is still a stigma attached to mental ill health and addiction, and all of us here and beyond still have a lot to learn about how we combat that stigma and treat the condition as a genuine illness and try to offer help to the individual as much as we possibly can.’

Labour’s Tom Watson recalled him joking that they probably shared the same private investigator from the News of the World. He broke with Commons convention and spoke directly to the solemn figure of Donald, sitting in the gallery. ‘Your father was a very great man; he stood up for what he believed in. He led a party of the centre-left with dignity and compassion. When you are older, you will know that your mum and dad believed in a cause greater than themselves and you will be proud.’

And Tim Farron, a contender for the Lib Dem leadership, did the same: ‘Charles Kennedy was a very, very special man. Donald, you should be really proud of your daddy. I am proud of your daddy. I loved him to bits. I am proud to call him my friend. God rest you, Charlie.’

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Westminster Publications is grateful to Mark D’Arcy and Ben Clover for their contributions to this publication.

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