Review of the Year Review of Parliament

2013 / 2014 HEALTHCARE EDITION

A YEAR IN PERSPECTIVE

FOREWORDS e Rt Hon David Cameron MP e Rt Hon Jeremy Hunt MP

REPRESENTATIVES Surrey and Sussex Healthcare NHS Trust Central Manchester CCG Countess of Chester Hospital NHS West Hampshire CCG NHS Foundation Trust NHS Dorset CCG University Hospitals Coventry Bury CCG and Warwickshire NHS Trust NHS Aylesbury Vale CCG Leeds and York Partnership NHS Foundation Trust Lincolnshire Community Health Services NHS Trust

FEATURES Review of the Year Review of Parliament

Foreword

The Rt Hon David Cameron MP Prime Minister

Four years ago our economy was in the danger zone. We But it’s not just what we are doing that matters, now have one of the fastest growing economies in the it’s why. Our ambitions are not only measured in developed world, and a better and brighter future for percentage points on a graph but in the families who Britain is within reach. This hasn’t happened by accident – have the hope of a better, more secure future; the it is thanks to the ongoing sacrifices and determination father who gets back into work after years unemployed; of the British people, and because of the long-term the moment when someone gets the keys to their first economic plan the government is working through. home, starts their first business, or receives their first pay cheque. The deficit is down by more than a third, safeguarding the economy for the long term and keeping mortgage Our recovery is real, but it has not been easy – as rates low. 25 million hard-working people have had the articles in this year’s The Parliamentary Review their taxes cut, helping families be more financially demonstrate, it is thanks to the ongoing resolve of the secure. There are 1.8 million more people in work – British people that our country is starting to recover that’s 1.8 million more people with the sense of security after such tough economic times. That is why it is so and dignity that comes with a job. Immigration is down important that we stick to the plan. and benefits have been capped, ensuring our economy delivers for people who want to work hard and play by We must continue to take the difficult decisions to the rules. And 800,000 more children are now taught help us build a better Britain; one that rewards those in good or outstanding schools, as we give the next who have put in, who contribute and who play by the generation a decent education, with the skills necessary rules. This way we can deliver a brighter future for our to succeed in the global race. country – with Britain standing tall in the world again and its people more secure at home. 44,000 people have received the life-saving cancer treatment they deserve, thanks to our Cancer Drugs Fund. Our Help to Buy schemes are enabling people to access an affordable mortgage and buy their own We now have one of home, with nearly 40,000 people already on the property ladder as a result. And with crime down the fastest growing to its lowest level since records began, people up and “ economies in the down the country can feel safer in their own homes and communities. developed world,“ and Those jobs that used to be sent overseas – they’re a better and brighter returning to these shores. The production lines that ground to a halt – they’re cranking into action. future for Britain is Businesses from all over the world are asking how they within reach can invest in our country.

FOREWORD | 1 Foreword

The Rt Hon Jeremy Hunt MP Secretary of State for Health

The success of our NHS, despite the pressures with year I have launched the Sign Up for Safety campaign, which it copes every day, is a testament to the hard which aims to halve avoidable harm over the next three work and dedication of NHS staff. It is also a success years, saving 6000 lives. I want to make sure every part story of which this government can be proud. of the service is putting patients first. That means better treatment for whistleblowers, and creating a culture of Compared to 2010, on a flat budget, more patients are openness and transparency. receiving a better quality of care than ever before. This is what is happening every single day: 1000 more people I see the evidence of progress each week when I go out with suspected cancers are being referred, and 1000 on the wards with our fantastic staff. But there is a long more patients are being transported in ambulances in way to go. As we welcome a new NHS leader in Simon emergencies. Every day we are performing 2000 more Stevens, we must face up to the major challenges that badly needed operations, we are seeing 3000 more face our health service now and in the years to come. vulnerable people in A&E departments, and every day The growing pressures of dementia, diabetes and other we are providing around 6000 more GP consultations long-term conditions will place new demands on the and 10,000 more vital diagnostic tests. At the same service, against a backdrop of constrained public spending time, MRSA rates have almost halved, mixed-sex wards and a need for efficiencies. Driving reform of care outside have been virtually eliminated, and fewer people are hospital, integrating the health and care systems, enabling waiting for 18 or more weeks for their operation. an IT revolution that will transform care and productivity, utilising the full potential of new treatment methods – The scale, operational performance and productivity of each will take focus and resolve in the next parliament. the NHS today is impressive. But more important is the way in which we have successfully put patient‑centred, The pressures of the 21st century would have been quality care back at the heart of the NHS. Compassionate almost unrecognisable to founders of the NHS in care, patient power and a zero-harm approach to safety 1948. But I believe that by bringing out the best in its are the values we have championed, spurred on by the exceptional staff and allowing innovation to flourish, the lessons of the Francis Report. service will – as ever – rise to the challenge.

The independent Commonwealth Fund now ranks the

NHS top in its comparison of international healthcare systems. And, critically, it acknowledges substantial progress in patient-centred care and safety, such that We have successfully“ put we now lead the field. patient‑centred, quality Tackling unsafe care should be at the heart of our “ care back at the heart of approach to this challenge. Unsafe care is the most expensive thing the NHS could possibly do, and with the NHS the Mid Staffs scandal we saw its terrible effects. This

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Simon Stevens appointed Chief Executive of NHS England

Britnell and Mike Farrar, the former head of the NHS Confederation – the latter having been widely tipped for the job before Sir David’s tenure began. After interviewing initial applicants, NHS England chair Sir Malcolm Grant is understood to have asked recruitment consultants to conduct the search for candidates on an international scale.

Jeremy Hunt praised Mr Stevens for The appointment of Simon taking a pay cut to take on the role, Stevens as Chief Executive and doing it for £20,000 less than of NHS England was his predecessor, The Daily Telegraph widely welcomed In April Simon Stevens took over from reported. Sir David Nicholson as chief executive of NHS England. Mr Stevens returned from Called by some ‘the biggest brain in the USA, where he was the president the NHS’, Mr Stevens faced a daunting of the global health division of private set of challenges on his appointment. healthcare firm United Health, to replace He inherited a system that was bracing Sir David Nicholson, who had announced itself for a repeat of the 2012–2013 his resignation in October 2013. winter A&E crisis, while still grappling with Andrew Lansley’s reform legislation, A former advisor to Tony Blair and passed the previous year. Spared the high-flying NHS graduate management former problem by mild weather and training scheme alumnus, his earlier than usual preparation, Mr Stevens appointment was widely welcomed has since made interesting moves to alter in the service. He was appointed over the regulatory framework he inherited. Mr Stevens signalled in other known contenders for the job, June that he would move KPMG global head of health Mark In Mr Lansley’s system, NHS England, towards letting CCGs organise the provision of controlling a budget of £30 billion, primary care was to commission specialised care and primary care. It held the latter portfolio to avoid accusations of a conflict of interest if GP-led clinical commissioning groups (CCGs) commissioned care from their member practices. CCGs were instead to commission everything in between specialised and primary care – a budget of £60 billion.

However, Mr Stevens signalled in June that he would move towards letting

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CCGs organise the provision of primary care after all, subject to mechanisms to avoid any conflict of interest, while allowing them a greater say in the commissioning of specialised care also. It is not known what NHS England got in return from GPs in exchange for these considerable strides away from Mr Lansley’s vision.

Another complex policy area Mr District general hospitals, Stevens inherited was what to do are increasingly losing work, and with it staff about England’s 73 small hospital process that would have seen it lose its expertise trusts. These organisations, defined as child heart services portfolio. having an annual turnover of less than £300 million under NHS finance rules, Consultation on large-scale changes were the subject of an investigation by to hospital services got under way economic regulator Monitor. in greater Manchester in July, and is expected to generate a lot of political These hospitals, much-loved by their heat, with MPs already campaigning to communities and fiercely defended have their local hospital designated ‘a by local MPs, often struggle to cope specialist centre’. financially in a service facing ever tougher cash entitlements from central After the furore surrounding ‘two‑tier’ government. However, there is a A&E services in November, when NHS growing body of evidence that they England set out its vision for how are less safe for complex procedures urgent and emergency care should than the larger metropolitan teaching best, and most affordably, be provided, hospitals, which can afford to staff their the service faces a problem the political rotas with specialists for longer periods. sensitivities of which are particularly acute in the run up to an election. The smaller trusts, often referred to as district general hospitals, are Mr Stevens cast further doubt on how increasingly losing work, and with smaller hospitals might operate in the it staff expertise, which can have future when he gave an interview to the knock‑on effects on their ability to Health Service Journal, in which hinted at provide other services. changes in education funding changing across the sector. Exactly how this will Attempts to formalise the transfer manifest itself has not yet been revealed. of these services have even seen challenges from independent There is still resentment among the foundation trusts in the High Court, larger university hospitals in London most notably the Royal Brompton & about a reallocation designed to at least Harefield Foundation Trust last year. partly redress the historic imbalance The trust lost its challenge but still between the capital and the rest of the managed to have the centrally run country in medical training budgets.

An eventful year for Jeremy Hunt

One of Mr Hunt’s big themes over this services. In April, the Department of year has been improving access to GP Health released Transforming Primary

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in the world of primary care, Transforming Primary Care is likely to increase the tendency of GP practices to work together in larger and larger groups, called ‘federations’ in many areas, to provide these services more comprehensively.

In July, Mr Hunt announced plans to increase the amount of money the NHS recovered from foreign patients, saying more rigorous enforcement of the rules could bring in up to £500 million a year for the service. Transforming Primary Care is a plan for more The Visitor and Migrant NHS Cost proactive and personalised Recovery Programme would see care that is focused on Care, a plan for more proactive and patients from outside the EU charged patients with the most personalised care particularly focused complex care needs 150% of the cost of any procedure on the 800,000 patients with the most to discourage ‘abuse’ of the system. complex care needs. Mr Hunt wants Hospital trusts will receive a 25% these patients, who are responsible for bonus on the tariff price they are paid a disproportionate number of hospital for each procedure if they notify the attendances, to have a named GP Department of Health of the nationality accountable for their care, a personal of EU nationals. There is already an care and support plan, and same-day agreement within the EU that sees the telephone consultations. NHS compensated for treatment given The named accountable GP is an to patients from the other 27 member expansion of the named doctor scheme states, but the government believes in hospitals, which was announced last that can be increased. year and was intended to make sure The British Medical Association patients did not fall between the cracks questioned whether frontline doctors of the different departments they were would have the time to enquire as transferred between. to the nationality of patients, and said that it was important that sick Patients from outside Consolidating a number of trends that the EU will be charged were already manifesting themselves people were not deterred from seeking 150% of the cost of any help. The Department of Health procedure to discourage guidance stresses that ‘immediately ‘abuse’ of the system necessary and urgent treatment’, including maternity care, must never be withheld from patients, regardless of whether they have paid up front. The scheme is being piloted in some A&E departments, and the Department of Health is setting up an intensive support team to spread best practice to other trusts.

The issue of nationality also came up in January, when the government confirmed it intended to alter the 1983 Medical Act to give the General

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Medical Council powers to take action where there are concerns about a doctor’s ability in the English language. There had been a call for the system to be strengthened in the wake of the Ubani case, in which a German doctor, operating as a locum GP in Cambridgeshire, fatally administered ten times the appropriate dose of diamorphine to a pensioner.

Mr Hunt has worked hard to make the NHS a non-issue for his party as it The past year has seen approaches the general election. Most steadily increasing activity that the system has commentators agree he has done a trusts, has gradually ruled out private struggled to keep up with good job of that so far: the question franchise management as options in is whether this can be continued. And all of these cases – although it is still Labour has promised to make the NHS being considered for Peterborough and the centrepiece of its campaigning over Stamford Hospitals Foundation Trust. the summer months. Mr Hunt seemed to move to disarm the issue in the run-up to the election by The past year has seen steadily telling delegates at a KPMG conference increasing activity that the system has that the debate over private or public struggled to keep up with. A national provision of NHS services was ‘utterly cancer waiting‑time target was toxic if it is decided by politicians’. breached for the first time in May, and there is no guarantee that A&E activity Another hangover for the government will not explode this winter, as it did from Andrew Lansley’s attempt to in 2012–2013. introduce more of a market into the NHS comes from the fate of The health secretary will have three commissioning support units. Although concerns about the service as his not included in the Health and party goes into the election: whether Social Care Act, these bureaucratic emergency activity can be contained, organisations were created when whether waiting times can be tamed the system’s designers realised there and if the money will hold out. Failure were many functions the abolished on any of these three counts would be Primary Care Trusts (PCTs) carried out difficult for an incumbent party. that could not be performed by their The health secretary’s position may successor Clinical Commissioning have been strengthened by moves Groups (CCGs). away from private-sector management The creation of 21 Commissioning of NHS facilities. At the moment, Circle Support Units (CSUs) was the solution Partnership manages Hinchingbrooke ordered by Sir David Nicholson, with Hospital in Cambridgeshire, and plans the idea being that these units, staffed were being considered for private by former PCT staff would compete providers, including Serco and Care UK, with the private sector to offer services to take over district general hospitals in Warwickshire, the West Country to England’s 212 CCGs. In April, a and Herefordshire. group of eight CCGs in north-west London announced they were ending The NHS Trust Development Authority, their contract with the CSU they had the arms-length body that is inherited and would be taking services responsible for non-foundation back in-house. Experts believe other

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Also in parliament, June saw the MP for Totnes and GP Sarah Wollaston take over from Stephen Dorrell as chair of the House of Commons Health Select Committee. The backbencher had won widespread praise in the health service for her sensible pronouncements on a host of issues. She also showed a measure of independence from the government when she said Andrew Lansley’s reforms had ‘tossed a grenade into primary care trusts’, when he gave them notice they would be abolished. MP for Totnes and GP Sarah Wollaston is now Mr Dorrell was also well respected as Chair of the House of chair, having been the health secretary Commons Health Select Committee CCGs across England could soon follow under the Major government from 1995, suit. If CSUs were to die out completely and he remains a presence in the NHS as this would be a blow to the idea that a non-executive director of King’s Health CCGs were anything other than GP-led Partners, a partnership between King’s PCTs, something that would strengthen College London, University of London Labour’s argument that the Lansley and three of London’s most prestigious reforms were largely ineffective. teaching hospitals.

Financial concerns in the NHS

conditions who needed its help. More recent analysis from NHS England and economic regulator Monitor suggests there will be a £30 billion funding gap within six years. But over the past year some have gone further and called for the overall NHS budget, approximately £100 billion, to be increased.

The first of these was Sir David Nicholson, the outgoing chief executive of NHS England. In the weeks before he was replaced by Simon Stevens, Sir David gave interviews in which he said the NHS would need an extra £2 billion if it were to stay in balance in 2015–2016. In July, Sir David Nicholson, the one poll reported that the public wanted outgoing Chief Executive to pay higher taxes in order to safeguard of NHS England, said the the NHS, something they were not NHS would need an extra Since 2009, senior leaders in the £2 billion if it were to stay prepared to countenance for any other NHS and beyond have warned that in balance in 2015–2016 public service. the system would struggle to cope with the growing number of elderly The same month, think-tank the people and patients with long-term Nuffield Trust published a report called

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In the Red? The State of the NHS’ Finances, in which it said ‘the NHS seems destined to experience a funding crisis this year or the next’. The report, by former Audit Commission head of health Andy McKeon and former treasury advisor Anita Charlesworth, said the only hope of staying in balance for many organisations was service transformation utilising ‘technological change, increasing the amount of care provided outside hospitals, reconfiguring the acute sector and focusing more on what patients can do for themselves’. But it concluded this Dozens of trusts ended the 2013–2014 financial year prospect ‘seems very distant’. in deficit under the NHS’s suppliers each year, and Lord Carter finance rules, and the Since the publication of the report, has been tasked with helping the number is predicted to rise finance directors at different levels of still further by the end of government fulfil its pledge of saving the system have said this crisis may well 2014–2015 £1.5 billion from this total by the end happen sooner or later. The hospital of April 2015. In July, the government trust sector, which is responsible for released data showing just how much around half of the NHS’s £100 billion variation there was in the prices paid budget, is under increasing financial for basic items across the service, strain as it struggles to reconcile rising with a toilet roll seemingly twice staff costs in the wake of the Francis as expensive in Sunderland as in Inquiry and reduced income from the Burton‑on-Trent. Department of Health.

Dozens of trusts ended the 2013–2014 The past year has also seen a slew of financial year in deficit under the private finance initiative (PFI) schemes NHS’s, sometimes arcane, finance rules. signed off by the government. The This number is predicted to rise still Treasury gave its backing to a PFI to further by the end of 2014–2015, with substantially rebuild the Royal Liverpool more trusts expected to say they will be and Broadgreen Hospitals in Liverpool, as unable to balance their books. well as the nearby Alder Hey Children’s Hospital. And it signed off a £165 million The government has pledged to saving But with many left unable to cut PFI deal for the specialist Papworth £1.5 billion on NHS staff costs they have turned instead Hospital in Cambridge in May. purchases of goods and to other costs such as procurement. services from outside suppliers by the end of The government appointed a new April 2015 ‘procurement champion’ in June, Lord Carter of Coles. The Labour peer previously ran the Co-operation and Competition Panel, which was the precursor to Monitor’s role as the competition regulator, and had written an influential report for the Labour government that recommended the NHS reform its pathology services to make them more competitive.

The NHS purchases £22 billion of goods and services from outside

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The PF2 contracts balance private equity with some government capital, and offer no control of the service subsequently provided in the hospital. A £353 million deal, featuring £100 million from the Treasury, was agreed in July to downgrade Sandwell and West Birmingham hospitals and replace them with the brand-new Midland Metropolitan Hospital. The hospital is due to open its doors in 2018, and the project will be watched closely between now and then to see The government has whether the government and local committed to a number NHS managers have managed to avoid of PFI schemes, including past mistakes on this kind of large one to substantially rebuild George Osborne also agreed a capital project. Alder Hey Children’s £420 million rebuild of the Royal Hospital Sussex County Hospital in Brighton There was further innovation within with traditional Treasury capital the sector as one hospital in the North funding and without the involvement East managed to pay off its PFI loan by of the private sector. borrowing from its local authority. The £100 million deal is not the first time In July, the Treasury gave the go-ahead an NHS trust has bought out its PFI, but to the first of the government’s ‘PF2’ Northumbria Healthcare Trust is the schemes in the health sector. These first to do so by effectively getting the variants of PFI schemes aim to avoid government to refinance the loan. the worst aspects of PFI deals, which have been heavily criticised as a bad On the national stage, the government deal for taxpayers. Not only have faces possible strike action over the the PFI deals tied the government to winter after Unison announced that expensive repayments for decades at over the summer months it would a time, the consortia that financed ballot its 300,000 members on strike and built PFI hospitals in the past were action. The union announced that if a allowed to decide who would provide yes vote is returned from its members facilities’ management services, which there will be stoppages in October often saw the NHS overcharged for followed by further strike action in the small maintenance jobs. autumn and winter.

Super-chains and super heads – the future of hospitals?

In February, Jeremy Hunt announced how the NHS can attract and retain the two linked reviews of management best leadership and change the culture in the NHS. Both will potentially have in underperforming hospitals. Mr Hunt a significant impact on how the NHS said the ex-M&S chairman would draw is managed. The health secretary on his experience leading one of the appointed former Marks & Spencer British high street’s best-known brands boss Sir Stuart Rose to lead a review of to offer guidance on how NHS leaders

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can be more visible and in touch with patients, services and staff on the frontline.

Sir Stuart is not the first high street name to be brought in to look at the efficiency of the public sector. In 2010 the government appointed Sir Philip Green, the former chief executive of Arcadia Group, which owns Topshop and Dorothy Perkins, to look at how effective government procurement was.

The health secretary has had strong Former Marks & Spencer words for the NHS before on its boss Sir Stuart Rose commitment to ensure high-quality care for every patient. Last year he said Care Quality Commission has now parts of the system were ‘coasting’, introduced a similar system with four and that this was costing lives. Mr Hunt different ratings. has already put his money where his Sir David, who runs the successful mouth is on attempting to change Salford Royal Foundation Trust in the management culture in the NHS: Manchester, has said he is interested in in September 2013 he announced how high-flying hospital management plans to spend £10 million sending a teams can be encouraged to help out cohort of 50 managers and clinicians the less successful. He said his team to Harvard Business School. Sir Stuart’s was investigating a system that could report is due at the end of this year, see well-known NHS organisations and is expected to cause a stir in senior taking over trusts hundreds of miles NHS circles. away as part of a campaign to drive up standards. At the same time as Sir Stuart’s commission, Mr Hunt appointed Sir Another intriguing possibility that Sir David Dalton to lead a review of NHS David has been asked to look at is trust governance models, potentially whether a mutual model of ownership with a view to high-performing could see a partnership of staff take organisations taking over struggling The Care Quality over the ownership of a hospital trust. Commission has ones. Mr Hunt likened this to the introduced a rating system ‘super head’ model in education, for hospitals similar to the where a ‘chain’ of schools is created Ofsted ratings for schools by stronger institutions taking over the management of weaker ones.

This follows the importing of other ideas and terminology from the education sector into health. Previously, Jeremy Hunt has said the Ofsted inspectorate system and rating of schools as ‘outstanding’ ‘good’, ‘requires improvement’ and ‘inadequate’ allowed parents to see at a glance how local schools were performing, and that he wanted a similar system for hospitals. The

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expressed an interest in pursuing that model of ownership.

The chief executive of University Hospitals of Leicester Trust has already indicated that his 1800-bed organisation might be interested in being taken over by its 12,000 staff. However, it is not clear if making such a large institution a social enterprise would require more legislation.

There are already some former NHS organisations that have reconstituted themselves as social enterprises under As part of his attempt to change the management earlier government invitations to culture in the NHS, become mutual organisations. But the Mr Hunt plans to send 50 This has been described as similar uptake on this kind of scheme has managers and clinicians to to the John Lewis ownership model. largely foundered on issues like transfer Harvard Business School And one large hospital has already of pensions and job security.

Savile and Morecambe Bay

June saw the release of one report 2012, former barrister Kate Lampard Twenty-eight NHS from a long-running inquiry and the was appointed to oversee three hospitals have investigated beginning of another. In October separate reviews of how Jimmy Savile the veteran entertainer’s came to have unfettered access to unfettered access to vulnerable patients vulnerable patients up and down the country. Twenty-eight NHS hospitals investigated the veteran entertainer’s abuse on the wards.

Dr Bill Kirkup, who was the lead investigator into Savile’s activities at Broadmoor psychiatric hospital, is now chairing the inquiry into the deaths of children at University Hospitals of Morecambe Bay. There has already been one investigation into the deaths, but this one will examine whether there were wider systemic failures at play, in the same way there were found to be failings in the wider NHS which allowed poor care to flourish at Mid Staffordshire Foundation Trust.

Announced in July 2013, and due to report this July, Dr Kirkup’s deadline has been extended to the autumn because of the volume of evidence submitted. The inquiry is likely to

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raise further questions over the role the end of 2014, with its two hospital of regulators Monitor and the Care sites being taken over by neighbouring Quality Commission. organisations. The trust was inspected by the Care Quality Commission in Meanwhile, the trust that has become June after recent concerns were raised the byword for NHS care failures, Mid about the quality of service it could offer Staffordshire, is due to be dissolved patients following recruitment problems. by the end of the year. In spite of multiple delays to the costly trust special The NHS will also feature in the new administration process, the organisation inquiry into child abuse in parliament is set to be decommissioned towards and the media.

The Keogh reviews and safety – 18 months on

In February 2013, David Cameron said he had asked NHS England medical director professor Sir Bruce Keogh to investigate 14 trusts that appeared to be outliers on mortality indicators, to check they were safe. Eleven of these were subsequently placed in special measures by Monitor or the NHS Trust Development Authority.

A year and a half after the Prime Minister’s announcement, only six remain in special measures, and the government boasts of improved care, leadership changes at some hospitals and increased staffing. In July, the Department of Health said the 11 trusts now employed 603 more nurses, 721 more nurse support staff, and 101 more doctors. It is not known whether the trusts have now improved their mortality indicator scores.

The special measures system, which is the same term used for failing schools, has now been extended to cover care homes and other parts of the health and social care system. Since the Keogh Review was announced, three trusts have been put into special measures that had not been initially identified.

These included Colchester Hospital, which has seen a police investigation Sir Bruce Keogh, NHS England Medical Director into allegations that staff were ordered

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trust resigned, and enquiries into the trust are ongoing.

Another trust in special measures made national headlines when it was revealed its new chair was to be paid more than £200,000 a year on a contract that would only oblige him to work three days a week. This was Medway Foundation Trust, a relatively small hospital in Kent, struggling with significant waiting time and access problems, which had seen multiple criticisms of its previous Eleven trusts now employ leadership. Monitor, the economic 603 more nurses, 721 regulator, which is also responsible for more nurse support staff, the regulation of quasi-autonomous and 101 more doctors to falsify records on how long cancer foundation trusts, defended the salary patients had waited, in order to hit of the new chair, saying the scale government targets. Both the chief of the challenge at the £252 million executive and chair of the north Essex turnover organisation justified it.

The ‘Francis effect’

There was a drive to improve safety an increase in the number of nurses and quality in England’s hospitals after employed in the NHS. the criticisms in the Francis Report Official statistics in June showed into care failings at Mid Staffordshire the NHS was employing 314,802 Foundation Trust. Christened the nurses, the highest number on record. The failings noted by ‘Francis effect’ by managers, it saw Robert Francis QC in his Although welcomed in government, report on Mid Staffs have led to a drive to improve this created problems of its own, as safety and quality many trusts struggled to recruit enough nurses to fill their rotas and increased demand saw agencies that provide temporary staff increase their profits.

Data from the economic regulator Monitor showed the amount spent by foundation trusts on contract and agency staff went from £1.078 billion in 2012–2013 to £1.373 billion in 2013–2014. The foundation trust sector had only planned on spending £523 million on temporary staff in 2013–2014.

Hospitals were also forced to recruit abroad en masse as the shortage of domestic supply became apparent.

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Delegations from English hospital trusts were sent to hire nurses in Ireland, Portugal, Spain and the Philippines over the course of the year – the economic downturn in many of these countries and the relative generosity of the wages in the NHS making the posts attractive.

One chief executive said the nurses she had recruited from the Iberian peninsula were surprised at the amount of low‑level ward care they had to provide in English hospitals, as in Spain or Portugal much The government of this care – providing meals and welcomed the record water – was done by a patient’s family. number of nurses being employed

Antibiotics and cosmetic surgery

In July, David Cameron pledged that procedures, such as the administering Britain could lead the world in the of botox. race to deliver a new generation of antibiotics. The Prime Minister warned The Department of Health called in that the pipeline of new antibiotics Professor Sir Bruce Keogh, the NHS coming out of the pharmaceutical England medical director and heart industry had slowed to a trickle. He surgeon, to look at whether there said a ‘market failure’ by the big drug needed to be better regulation of the firms meant that no new class of £2.3 billion cosmetic-interventions antibiotic had been discovered since industry for the protection of the 1987. This, he warned, could see public. At the start of this year the medicine return to the ‘Dark Ages’ Department of Health accepted the when a scratch that became infected recommendations Sir Bruce had made could become fatal. in his report, and said work had already started on a number of them. The pipeline of new He announced an independent antibiotics coming out of the pharmaceutical review into the issue, funded by the industry has slowed to a Wellcome Trust, into how to increase trickle international cooperation on the issue and how governments can encourage investment in the research.

In February, the government also moved to address another public health story, one that had first hit the headlines in 2012: faulty Poly Implant Prothèse breast implants, some of which were found to be leaking or contain substances that should not have been placed in human bodies. The news then had prompted complaints about the regulation of other popular

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The Royal College of Surgeons has set up a committee working across the different specialties in the cosmetic surgery field to draw up a code of conduct with the General Medical Council, while Health Education England is leading a review of the training given to providers of non‑surgical procedures such as botox and dermal filler injections. A breast implant registry will also be created to reassure women that if problems arise in the future they can be notified and A code of conduct is being drawn up for cosmetic called in for treatment quickly surgery practitioners

Waiting times and A&E performance

Performance on waiting times and system whereby prostate cancers are cancer saw some dramatic and worrying removed from the 62-day waiting-time news over the past year. For the first target, in order to reflect the decision time since the introduction of cancer by many patients to defer treatment treatment waiting-time targets in 2009, because of the side-effects. However, the English NHS missed the target of the government has no plans to do treating 85% of patients within 62 days so, and there are indications that of their urgent referral from a GP. the situation for cancer waits may get worse. The slide in the last quarter of 2013–2014 saw not only a deterioration in the Another iconic access target was position of the worst-performing trusts breached for the first time this year. but a worsening of the mean across The total waiting list for patients The total waiting list wanting an elective treatment, for patients wanting an the country, with many prestigious elective treatment topped teaching hospitals recording breaches everything from outpatients three million for the first of the waiting-time target, particularly appointments to hip replacements, time since March 2008 for urological cancer. topped three million for the first time since March 2008. The size of the NHS leaders said hospitals were waiting list has fluctuated since then, struggling to cope with increased but has generally stayed around the demand and a lack of basic diagnostic 2.5 million mark. However, since capacity that saw bottlenecks in the December 2012 it has grown steadily. treatment of common cancers like that The government points out that this of the bowel. Others pointed to an is partly down to hospitals treating a increase in referrals thanks to a number backlog of patients who have waited of public health campaigns focused on more than a year for treatment. helping the public spot the symptoms of some of the more common cancers, The 18-week waiting standard, which as well as the government’s bowel says 90% of patients should be treated cancer screening programme. within 18 weeks of referral for elective procedures, has not been breached at There were calls from some quarters a national level so far, but critics say it for the English NHS to adopt the Welsh has discouraged hospitals from treating

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patients once they have breached the 18-week target –hospitals must treat nine patients for whom the 18-week target has not been breached for every one for whom it has, and this sees the number of those waiting for a year or more build up.

Foundation trust regulators sent a warning to hospitals in July saying they must prioritise those who have been waiting the longest, even if this means they breach the overall waiting-time targets.

Efforts to tackle waiting-list problems have been hampered by doubts about the quality of the data. Following the abolition of the Audit Commission, trusts have had only patchy arrangements for the external audit of their waiting-times statistics.

In April, the House of Commons Margaret Hodge, Public Accounts Committee (PAC) Chair of the House of published its report on waiting times, Commons Public Accounts after an investigation by the National Record numbers of trusts are not able Committee Audit Office. The National Audit to report their waiting-time statistics Office reviewed cases at seven trusts, to the Department of Health because finding that waiting times for nearly of problems with IT, often with the a third of cases were not supported Lorenzo IT system, a legacy of the by documented evidence and that government’s disastrous Connecting more than a quarter of the documents for Health programme. examined contained at least one error. As one of the most visible NHS PAC chair Margaret Hodge MP performance targets, the government said: ‘Trusts are struggling with a is ploughing more money into dealing hotchpotch of IT and paper-based with waiting lists. In June, NHS England systems that are not easily pulled announced a £250 million fund to together’, and called for independent improve access to elective procedures, audit of waiting‑time data to be similar to the one unveiled after the resumed – something echoed winter A&E crisis in 2013. by Monitor. The A&E situation has stabilised A string of trusts have now admitted somewhat since the well-documented to having ‘hidden’ waiting lists, where failings in hospitals the winter before patients they were not aware of last, but is still not good. Performance suddenly appeared on their systems. at major A&E units is still below target, Barnet and Chase Farm Hospitals, and, while the situation always eases Moorfields Eye Hospital and Salford over summer, when there is a larger Royal Foundation Trust were among net attendance but a lower acuity of the organisations that have had to patients, ministers will be anxious to admit a major, and hidden, problem ensure the coming winter is not as bad with long-waiting patients. as the one in 2013. The colder months

16 | REVIEW OF THE YEAR HEALTHCARE EDITION

was being compromised by the understaffing of the departments.

CEM president Clifford Mann said the gruelling nature of A&E shifts and working at weekends made the specialism unattractive to senior doctors, who preferred to specialise in a field with more sociable hours. He called on the Department of Health and subsidiary body Health Education England to increase the amount of time trainees spent in A&E so there was a greater pool of experience to call The gruelling nature of on in the future. the shifts and working at weekends makes The college also argued that, rather specialising in A&E there saw some hospitals forced to than trying to get the public to access unattractive to senior take eye-catchingly extreme measures patchy out-of-hours GP services, GPs doctors in order to cope with demand, and should set up primary care centres next in many case ambulances backed to A&E departments, to reduce the up outside emergency departments, burden placed on emergency services unable to transfer their patients. by patients who are not seriously ill.

The College of Emergency Medicine Sir Richard Thompson, president of (CEM) drew attention to the parlous the Royal College of Physicians, told state of the consultant workforce in The Daily Telegraph that without A&E departments. The organisation for improvements to the system the NHS senior doctors working in emergency would ‘simply walk blindfolded into departments said the quality of care another winter crisis’.

The Better Care Fund

In June 2013, ministers made what government. As further details emerged The Better Care Fund could turn out to be the most significant this year, it became clear that the could mark a significant health policy announcement of this innocuously named Better Care Fund step towards the full could have a dramatic effect on the way integration of health and social care services the NHS interacts with local authorities. The scheme will see £3.8 billion of NHS money transferred to a fund controlled jointly by the NHS and local authorities. It will start in April 2015, and as health minister Norman Lamb and local government minister Brandon Lewis pointed out in their letter to both sectors in December, it ‘is the biggest ever financial incentive for councils and local NHS organisations to jointly plan and deliver services, so that integrated care becomes the norm by 2018’.

REVIEW OF THE YEAR | 17 THE PARLIAMENTARY REVIEW Highlighting best practice

The money is intended specifically to improve the interface between the NHS and local authorities – a connection that has often struggled at the point of transferring patients out of hospital and into council-run care homes. Delayed transfers of care are thought to be one of the biggest factors in the 2013 winter A&E crisis, with it not being possible to send home patients who were well enough to be discharged from a hospital bed because adjustments were needed to their homes to help them cope with their increased frailty. One of the aims is to The Better Care Fund is also intended increase the ability of primary care services and to increase the ability of primary care The Better Care Fund, comprising just local authorities to treat services and local authorities to treat people in the community under 4% of the NHS budget, could people in the community, reaching mark a significant step towards the them before they require an expensive full integration of health and social hospital admission. care services – a move that has been While all have applauded the aims, mooted for some time by parties from there have been warnings from across both sectors. How this agreement the health service about the transfer of between the NHS and the social care the money, including from departing sector in England works will be evident NHS England chief executive Sir David at the end of the winter. Nicholson, who said the transfer, Health Minister Norman with the money being top-sliced from Lamb local clinical commissioning groups, could see hospital trusts collapse if schemes to prevent admissions to an acute setting fail to deliver. In most years, commissioners announce their intention to halt the increase of people being referred to or visiting hospital, and each year attendances increase.

Matters were not helped by the Secretary of State for Communities and Local Government Eric Pickles telling a conference of council leaders that he had secured £3.8 billion of NHS money for them. After representations from the Foundation Trust Network and others, the Department of Health has drawn up a set of contingency funds that would see parts of the Better Care Fund reallocated to hospitals to help them cope if the schemes in the community fail to control demand.

18 | REVIEW OF THE YEAR HEALTHCARE EDITION Surrey and Sussex Healthcare NHS Trust

East Surrey Hospital is one of the busiest blue light hospitals in the region

Michael Wilson, Chief Executive urrey and Sussex Healthcare NHS Trust provides emergency and non-emergency services to half a million people across Seast Surrey, north-east West Sussex and South Croydon, as well as the thousands of people that pass through Gatwick Airport every day. ABOUT US

The trust’s main site is East Surrey Hospital in Redhill. It is an Surrey and Sussex associated university hospital of Brighton and Sussex Medical Healthcare NHS Trust

School. It also has partnerships with both the Royal Surrey » 28,000 planned day cases, County and Guy’s and St Thomas’ Hospitals to bring specialist up 6%

services to the East Surrey Hospital site. East Surrey Hospital is » 5000 planned inpatients, the busiest blue light hospital in the region, and has a higher down 1% than average number of unscheduled patients (60%). » 294,000 outpatients, up 17%

Surrey and Sussex Healthcare NHS Trust is not only one of the most improved but » 4500 babies delivered, also one of the best performing trusts in England. In less than three years we have up 3.5% transformed the organisation’s performance and culture. In the past 12 months the » 5000 chemotherapy quality of our services has gone from being compliant to being consistently excellent. treatments, up 7% In our recent inspection by the Care Quality Commission (CQC) we achieved an overall ‘Good’ rating as well as being awarded a ‘Good’ rating in all five assessments » 82,000 attendances at the of quality: how safe, caring, effective, responsive and well-led our services are. This emergency department, judgement puts our trust among the very best in the country. In a recent poll, our up 2% staff were asked which three words came to mind when thinking about our trust. The top three answers were ‘caring’, ‘improvement’ and ‘patient‑centred’.

People talk: it is our patients describing their great experiences and our staff recommending our trust as a place to work and be treated that is giving everyone

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highest response rates in England, with staff saying they felt that what they do makes a difference to patients. » For the second year running our staff are among the most motivated NHS staff in the country, and they said they are proud to recommend our trust as a place to work and be treated. » Our organisation is one that is ‘clinically-led and managerially enabled’, and clinical leadership and engagement is high.

We focused on four things: our patients’ safety; the quality of our services; our Dr Allard, a junior doctor patients’ clinical outcomes; and our on the Acute Medical Unit is often praised for how he patients’ overall experience. We knew communicates with patients that by getting these four things right the confidence in the quality of our statistics would take care of themselves. services. This is a far cry from when we were in the bottom 20% of trusts for For example, when the weather patient and staff satisfaction, did not was getting hotter last summer, our meet performance targets and had to emergency department kept its cool and take out the largest loan ever given to delivered the best monthly performance an NHS trust. of all NHS trusts in England, while at the same time maintaining admitted That was then, and this is now: and non-admitted access targets and » The CQC has given our trust a clean bill ensuring that the hospital maintained its of health, and rates our trust as ‘Good’ trauma unit status. This is a remarkable after a rigorous inspection process led achievement given that a few years

by the Chief Inspector of Hospitals. earlier it had been the worst performing emergency department. Now the

» The CQC’s Intelligent Monitoring department consistently delivers the process consistently ranks our trust in A&E waiting standard, and was the “ the top 25% of trusts for having the The patient best of all the hospitals in the region lowest level of risk. voice runs and 24th in the country for 2013. » The Friends and Family Test score for “ through all our emergency department has been With the performance of the emergency the best in the region and had the department on track, we have we do fifth best response rate in England. concentrated our efforts on ensuring we » Patient Opinion, a respected online can meet the increasing demand for beds forum, rates us as one of the in our hospital. This is another example most improved trusts for patient of how our impressive performance has satisfaction, and commends our stemmed from our focus on patients’ ‘making things right’ responses. experience. The turning point for us was the successful mapping of doctors’ rotas » The 2013 inpatient survey shows us to patient‑centred demand, giving shifts as ‘statistically significantly improved’. later in the evening and at weekends, » We are ranked in the top 25% of trusts with better handover protocols and in England for lower than expected more days off. This halved the waiting mortality rates by the independent time for patients in the evening and Dr Foster Hospital Guide. overnight. We also introduced a new » 68% of staff responded to the 2013 type of clinician to the trust – physician staff survey, which is one of the assistants enhance the continuity of care

20 | SURREY AND SUSSEX HEALTHCARE NHS TRUST HEALTHCARE EDITION for patients in terms of timely assessment Our buildings, facilities and the and review, and ward care. With fewer atmosphere in our trust is unrecognisable patients being handed over from day from even two years ago. We have to night shifts, patients are benefiting realised opportunities for financial from early treatment, and therefore investment and savings, and this has have better outcomes. allowed us to grow. Once you make the change it starts to take on its own We have worked closely with our momentum. There is a sense of pride local community health partners and and achievement across the trust now, clinical commissioning groups to and an ambition to do more. We have provide and jointly fund 60 extra beds achieved this because everybody in the in local nursing homes and community trust has four simple things fixed in hospitals. These beds are for patients their thinking: safety, quality, clinical who are well enough to leave hospital effectiveness and patient experience. but still need some ongoing support and rehabilitation. By creating these The work towards our goals has been driven by clinical leadership, effective additional beds we can confidently Care and compassion on our discharge patients to the care of the communication, enthusiasm, lessons wards help give our patients a community health providers, and release learned, being open and being transparent. good experience our acute beds to admit new patients. Our trust has moved from having a poor reputation based on poor patient The patient voice runs through all experience to being, and being known as, we do, and never before has ‘patient one of the safest hospitals in the country. experience’ carried as much importance as it does now. We are one of the Patients and their relatives today expect country’s leaders in listening to, hearing a good experience when they are and acting on what our patients tell us. admitted to hospital, and they rightly demand a smooth transition through We are doing very well on our Friends the healthcare system. We have more and Family Test scores, and use the to do, but more than ever before we information this provides. In addition, have a workforce that is excited by our bespoke Your Care Matters being asked to deliver care that they programme tells us a lot about what we would want for themselves. We want do well and what we need to do better our patients to have a great experience at individual ward and department level. and a seamless journey to care in the We have received more than 10,000 community. By getting this right we responses since the programme was will help build the NHS of the future. launched in 2012, and many of these have already triggered changes that benefit our patients. Comments from » CASE SUDY patients about noise levels on wards at night have prompted revised evening Our Medical Division has embraced seven-day working, and we now have staff rotas and cleaning work patterns, significantly increased consultant and junior doctor presence at the weekends moving the nurses closer and the staff in acute medicine, general internal medicine, cardiology, gastroenterology bases further away from patient beds, and geriatric medicine. Availability of senior and junior staff has been mapped installing new soft-close bins and fixing to patient need, and all medical wards are now visited by consultants seven squeaky doors. It is actually these really days a week. This means we can discharge patients who are well enough small details that are often so important. to leave our care without having to wait until the Monday ward round. We have developed our ward rounds to focus on the patient, and ensure a We have also embraced Patient Opinion, better quality conversation and information exchange. Our simulation training with our consultants, matrons and our for junior doctors in ward‑round technique has been adopted as a regional chief nurse regularly responding directly training programme to equip final-year medical students to perform with to patients within 24 hours of their more skill and confidence as foundation-year doctors. comment.

SURREY AND SUSSEX HEALTHCARE NHS TRUST | 21 THE PARLIAMENTARY REVIEW Highlighting best practice Countess of Chester Hospital NHS Foundation Trust

Our main site in Chester – we have another facility in nearby Ellesmere Port

Tony Chambers, Chief Executive s Chief Executive, I want The Countess of Chester Hospital NHS Foundation Trust to be nothing less than ABOUT US Athe most clinically engaged and clinically led healthcare provider in the country. At this remarkable and successful district Countess of Chester Hospital general hospital we are turning traditional models of NHS NHS Foundation Trust leadership and management on their head. A cadre of highly competent clinicians has stepped forward to re-energise, refocus » A 600-bed district general hospital, and a 70-bed and reinvent the organisation to deliver new models of care to rehabilitation and outpatient meet the demands raised by an increasingly ageing population. facility

» Over 3500 employees This year we celebrate our history: 100 years of our Ellesmere Port Community » Serves 250,000 residents, Hospital, 30 years since our Chester city centre site was opened by Princess Diana, mainly in Chester and the and 10 years working as a foundation trust. Now, together with our doctors, nurses, surrounding rural areas, midwives and therapists, we are writing the story of our hospital of the future. Ellesmere Port and Neston and the Deeside area of We are very clear about the specific and unique challenges faced by both our staff Flintshire and our patients. Based in a walled city with spectacular views of the nearby rolling Welsh hills, Chester is a place that is historically, geographically and culturally » Provides acute emergency rich. Boundaries and borders pervade the local landscape. Yet we work in an NHS and elective services, primary environment where every day we are asking our workforce to push themselves, care direct access services to innovate and work beyond their organisational boundaries and beyond the and obstetric services hospital walls. » More than 425,000 patients attend the hospital for As one of the first foundation trusts in the country, this is a comfortable place to treatment every year come to work every day. Financially we are strong, with powerful performance. Relationships with commissioning and provider partners are respectful and healthy.

22 | COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST HEALTHCARE EDITION

We are successful, and pride abounds. Hospital-at-home services have There is no burning issue that requires expanded significantly, and are us to change. So the challenge facing providing a rapid discharge option the leadership of this hospital is how for more than 100 patients at any we swiftly move from delivering good one time. This is at least three times patient care to consistently delivering more cost-effective than treatment great patient care. To do this we have being provided in a hospital bed, and to call entirely on our own resources. we have reduced the hospital acute We need our clinicians, in partnership bed pool. with managers, to ignite a sense of collective ownership and individual By front-loading investment in We need our responsibility. We want to showcase state‑of-the-art diagnostic equipment, clinicians, in the district general hospital as the jewel including an additional MRI scanner, in the crown of the NHS, and not the a brand new endoscopy suite and an “ partnership with ‘stone in the shoe’ as it has come to expanding CT scanner capability, we be perceived. can move more rapidly to a position of managers, to treatment planning.

In the future the accident and ignite a sense emergency department will no The leading physician for urgent care of collective “ longer act as the front door to the is actively participating in work with hospital, but will become the back the Royal College of Physicians on ownership door of community services. Our The Future Hospital Commission, acute-care hub will be the centre of which was established to review all and individual clinical expertise, fast diagnostics, aspects of the design and delivery of responsibility multidisciplinary assessment, treatment inpatient hospital care. We believe in planning and rapid transition to other this direction, and will work with our health and social care environments. generalist and specialist physicians as If we get this right, 80% of people well as our surgeons to understand will be seen, assessed and discharged how we adopt it across the local within 48 hours. health system. Meanwhile our medical director is working with the University The principle is to focus on the needs of Chester and local health and of the patient and to have a more social care partners to pioneer new tailored health-service response. models of education that address the This year we have opened a Patients with complex needs will new £15 million building for have skilled and experienced nursing our intensive care unit and staff to care for them. Patients with endoscopy services more generic needs will be managed through high-flow facilities with staff trained to manage their different care needs. Specialist nursing input to the ambulatory and short-stay areas will be within easy reach of teams based in complex ward areas, with staffing levels adjusted to reflect this.

As patients arrive at our accident and emergency service, those who can walk in through the front door are directed to an enhanced ambulatory care unit, which is already operating six days a week and reducing pressure on the accident and emergency service.

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shortages in generalist medical skills. If we provide emergency, urgent A formal collaborative agreement has and specialist care quickly, efficiently been signed by both organisations and more safely in a smaller, better establishing an academic institute organised hospital, and if patient for integrated health and social care outcomes are the best possible, then research, hosted by the trust. we will have improved on what we are doing now. Prime provider contract discussions with local commissioners mean we plan We will have succeeded in challenging to take these changes further, and at a and redefining the boundaries and pace to help meet the funding shortfall borders for The Countess of Chester, facing our health system. We have to and be valued by this walled city and see this situation as an opportunity – its local community for being so much an opportunity to think differently and more than a hospital. to make fundamental changes to the way we organise services.

If we end up in five years with more patients cared for at home, or near More than 3500 employees where they live, and if we achieve work for the trust a service where the NHS, social services and the voluntary sector are consistently working closely with families and patients to help them remain within their communities, then we will have made lives better for thousands of people.

»OUR STRATEGIC VISION

To transform our services to deliver the highest quality, safest patient care through committed and capable people.

We have established five key strategic objectives to achieve our vision:

» Providing the best possible patient experience through providing the best clinical outcomes and the highest quality care in a safe, friendly environment where a patient’s dignity is fully respected. We intend to continuously make improvements in the patient experience and reduce the incidence of harm. » Efficiency and quality in delivering services, through maximising our operational efficiency and productivity and redesigning service provision. We aim to deliver streamlined, accessible services to patients, in a place that it is most convenient to them, and with the lowest waiting times. » Listening to our patients. Patients are not our only customers – their relatives, friends, visitors, the GPs who refer them and the bodies that commission our services are important too. By listening to our customers and using their feedback, and by working in partnership with our commissioners, we will continuously improve the services we provide. » Pushing boundaries. Always moving forward and changing things for the better, expanding the scope and range of services – life-changing innovation, from the application of the very best clinical practice through to process transformation and the use of the latest technology. » People at their best. Meeting our ambitions for customers rests on our staff – engaging, empowering and recognising our people will make sure they can give their best and continuously drive improvement in the delivery of services.

24 | COUNTESS OF CHESTER HOSPITAL NHS FOUNDATION TRUST HEALTHCARE EDITION University Hospitals Coventry & Warwickshire NHS Trust

Some members of the Getting Emergency Care Right team

Dr Meghana Pandit FRCOG MBA, Chief Medical Officer niversity Hospitals Coventry & Warwickshire NHS Trust (UHCW) aims to provide top-class specialist services Uwhile continuing to provide excellent care to the local ABOUT US population on its doorstep. Our vision is to become a national and international leader in healthcare. University Hospitals Coventry & Warwickshire NHS Trust

At UHCW we run two hospitals – a modern, private finance initiative (PFI) facility, » Provide care to over 1 million University Hospital at Coventry, and the Hospital of St Cross at Rugby – from which people we provide care to over a million people from Coventry, Warwickshire and beyond. No. of people attending an We aim to develop our existing relationships with Warwick University and Warwick » Medical School and Coventry University to be a leading centre for education, outpatient appointment: research and innovation. Our mission is to ‘Care, Achieve and Innovate’, and our 574,242 clinical strategy is to deliver our services via a hub-and-spoke model, which will » No. of outpatient enable us to meet our vision. appointments: 619,438

UHCW is an organisation of people with enormous talent and potential, led by » No. of people attending Mr Andrew Hardy as CEO. I have been Chief Medical Officer at UHCW for two A&E, including specialist years. This is my first board-level appointment, and performing these roles along children’s A&E: 176,485 with being a practising clinician has been an exciting challenge of which I have » No. of inpatients and day loved every minute. I led the development of our clinical strategy, which refreshed cases (based on admissions): our approach and determined how we provide services within Coventry and 142,389 Warwickshire. For this, I used action research and appreciative inquiry techniques, involving several doctors, nurses and managers so that everyone at UHCW owns » No. of babies delivered: this clinical strategy. I have been able to do this well because of the commitment 5995 and support of my colleagues at every level of the organisation. This is particularly » No. of patients operated on evident in the outcomes of our change programme, Getting Emergency Care in theatres: 41,157 Right (GECR).

UNIVERSITY HOSPITALS COVENTRY & WARWICKSHIRE NHS TRUST | 25 THE PARLIAMENTARY REVIEW Highlighting best practice

performing so well in terms of daily discharges, writing prescriptions and daily reviews » engaged with junior doctors productively » rewarded staff on their efforts by thanking them with a GECR badge.

This is when visibility of those in leadership roles mattered. Our top 100 leaders visited wards to offer support, showing that they cared. Within six weeks our position with regard to national performance for A&E targets improved so that we were The Tissue Viability Team one of the best performing trusts in the has significantly reduced the incidence of pressure ulcers country. This was possible because of After months of hard work, we felt the effective leadership demonstrated we had hit a wall in our accident and by clinical and non-clinical teams, emergency (A&E) department, and enabling sustained change. Ultimately, staff morale was at a nadir. We were the Secretary of State for Health, the criticised externally, and knew we Rt Hon Jeremy Hunt, congratulated could, and needed to be, better. GECR our CEO on our excellent performance. provided a golden thread that motivated Such hard work by our teams meant staff to work collaboratively to deliver that over 7000 patients got the right the best results for our patients. care sooner this year compared with last; an achievement that our staff We: should be rightly proud of. » used power training to disseminate Our Tissue Viability Team has similarly the GECR principles rapidly demonstrated impressive leadership » developed a simple metric that was in reducing the incidence of pressure displayed weekly on the trust’s intranet ulcers, also known as ‘bed sores’, » congratulated the ‘stars’, and which cause great discomfort, and in supported those who were not serious cases pain and infection, to

»LEADING THE WAY FOR BETTER PATIENT CARE

Among our achievements and innovations at UHCW are:

» Our clinical and information and communications technology (ICT) teams introduced and embedded Electronic Results Acknowledgement (eRA), which enables clinicians to acknowledge the results of tests they request, and act on them within a week for routine tests and within 48 hours for urgent tests. Patient care is enhanced by this initiative, which was shortlisted for the IT Industry Awards. » We are part of the West Midlands Academic Health Science Network, and we lead on education. Innovation Champions at UHCW help staff develop ideas into projects, to move from laboratory research to remarkable advances at the patient’s bedside. » We have a world-class surgical training centre, where work on three-dimensional cadaveric images and plastinated models attracts budding surgeons from across the world. » Our pathology laboratories are the first in the UK to report histopathology slides digitally. This increases accuracy and efficiency, and undoubtedly improves patient care.

26 | UNIVERSITY HOSPITALS COVENTRY & WARWICKSHIRE NHS TRUST HEALTHCARE EDITION patients. The 100 Days Free campaign excellent team whose contribution I led to eradication of the most serious respect and value tremendously. I listen level (grade 4) pressure ulcers and a to their views and opinions, and enable massive reduction in grade 3 pressure them to do their best. I consider it my ulcers on wards at UHCW. As a result, job to ensure that we all work to our the team won many national awards, best ability and offer patients the best and is now looking to take this ethos possible care. It is imperative that we into the community to help those communicate with staff, listen to their UHCW is an who are cared for at home too. This concerns and make their work innovative thinking beyond our hospital environment a place that they like and organisation walls is crucial to how the NHS is going one that draws the best out of them. to care for patients in the future, and “ of people with“ I am proud that at UHCW we already Ultimately, at the heart of everything enormous have staff embracing this. I do as Chief Medical Officer, I ensure that the rationality (i.e. purpose talent and At UHCW, with more than 6500 staff, of my actions) and the emotion we subscribe to visible leadership. (i.e. my values) meet. Doing this potential My executive colleagues and I visit enables me to lead by example, and different clinical and non-clinical areas provide confidence to our clinical and of our hospitals every day. We talk to non ‑clinical teams in my and their own staff and patients to acknowledge the actions to effect long-standing change difficulties they face. We respond to and improve care for our patients. concerns and complaints in an open and transparent manner. Our We are Listening campaign placed executive directors in ‘listening booths’ at the UHCW has a state-of-the-art surgical training centre main entrances to our hospitals, and the whole board listens to a patient story every month in different formats. This year, on NHS Change Day we launched Together Towards World Class, our organisational development programme led by Mr Andrew Hardy, unveiling our values which were developed with input from staff: compassion, openness, pride, partnership, improve and learn.

Following the report by Robert Francis QC on the public inquiry into Mid Staffordshire NHS Hospitals Foundation Trust there is a tense atmosphere in the NHS, with medical and nurse directors carrying huge responsibility and accountability. The constant need to achieve a balance between quality, effective operations and finance is challenging, and although there is evidence that good‑quality care costs less, we have to continue to work hard at constantly improving all aspects of clinical quality, while developing metrics that provide demonstrable evidence of financial balance. I have an

UNIVERSITY HOSPITALS COVENTRY & WARWICKSHIRE NHS TRUST | 27 THE PARLIAMENTARY REVIEW Highlighting best practice Leeds and York Partnership NHS Foundation Trust

The allotment programme – promoting fitness and healthy eating Clive Richards – the Get Me campaign changed attitudes to people with learning disabilities eeds and York Partnership NHS Foundation Trust provides mental health and learning disability services to people within LLeeds, York and parts of North Yorkshire. Specialist inpatient psychological medicine, low-security forensic psychiatry services, ABOUT US inpatient care for young people and a mental health service for Leeds and York Partnership deaf children are available to people from further afield. NHS Foundation Trust

» Serves Leeds, York and parts Leeds and York Partnership NHS Foundation Trust is a campaigning organisation. of North Yorkshire In 2012 the Get Me campaign changed attitudes toward people with learning » Provides specialist mental disabilities. This year we have participated in Time to Change, which is led by Mind health and learning disability and Rethink, the mental health charities, and the website Mental Health Media. services It is England’s most ambitious programme to end discrimination faced by people with mental health problems. Locally, we are developing a strand of the campaign, » Around 3000 service users with partners including Young Minds, NHS Airedale, Bradford and Leeds councils, every day Space 2 and Leeds Mind. The young people that we work with are creating school » Over 2000 people in contact projects to encourage children to think and talk about mental health. with services every day Recovery and person-centred care are at the heart of all our services. Programmes » Over 15,000 foundation that focus on self‑confidence are being delivered in partnership with service users trust members and carers. It is envisaged that people will rely less on statutory services in favour of » Teaching, research and self‑management using digital technologies, the development of peer support workers development and collaboration with voluntary sector partners. My Recovery Pathway has been piloted and evaluated within our services at different locations, and the initial feedback from » 3700 staff and over 300 service users is that the pathway is useful in enabling collaborative assessment. volunteers

» £175 million annual turnover To complement the recovery programme, the trust has engaged Rommi Smith, our creative writer in residence. Rommi works with teams to encourage people who

28 | LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST HEALTHCARE EDITION use our services, staff and members of training organisation. Our contribution the public to share their own stories to the Health Education England (HEE) of recovery, to encourage others and programme Better Training Better build understanding of mental health. Care (BTBC) was commended by HEE The 2013 Annual Members Day was Chairman Sir Keith Pearson when he themed around storytelling. visited our BTBC pilot team.

Measuring the effectiveness of the Our participation in BTBC has already care we provide is important to us. benefited junior doctors by increasing There is a strong history of some of our their access to supervised patient services using outcome measures, and contact in daylight hours, improved Recovery and in the future we intend to invite all our measurable communication skills using service users to record patient-reported the Situation, Background, Assessment, person-centred“ outcome measures. Consultation with Response, Decision (SBARD) tool, and “ care are at the staff and service users has shown that encouraged greater integration into for many services the Short Warwick– multidisciplinary teams. It has been heart of all our Edinburgh Mental Well-being Scale shown that delivery of clinical simulation (SWEMWBS) will enable service users training is more effective when delivered services to assess their progress and teams within a multiprofessional setting. to reflect on their own performance. In collaboration with the clinical Doctors will incorporate this work in commissioning groups (CCGs) in their annual appraisals. Leeds, the trust undertook a radical The recovery model has also been transformation of its services for adults extended to our approach to helping with a view too making them more people in crisis. Managers at the trust efficient. Among the changes, referrers invited clinicians and service users to are now directed to a single point of reconsider our approaches to clinical access, to avoid unnecessary delays, and risk management. Specifically, we are there are fewer referrals between teams determined to rely less on tick-box so that people do not have to retell their assessments, which may not necessarily stories unnecessarily. Services are based Time to Change – an ambitious address the needs of a person, and on the needs, rather than the age, of programme to end discrimination faced by people with mental the patient. In addition, alternatives instead concentrate on collaboration health problems with service users to develop a to hospital admission have been multidisciplinary safety plan. Using a developed, and in the last year the use compassionate approach, clinicians and of out-of-area beds has been reduced service users are now encouraged to by 90% for patients from Leeds. embrace positive risk management. This transformation provided the trust Enhanced clinical risk management with an opportunity for action learning. training is now being rolled out across We have studied the outcomes of the trust, which is proud to be a the project and intend to publish the results in a peer-reviewed journal. »MY RECOVERY PATHWAY Notable recommendations that may benefit other organisations include: The three components of My Recovery Pathway are: » to be clear from the outset about how objectives will be achieved, and » Starting from here – strengths to use few but relevant indicators and needs » to have clarity about the role » Goals – where I want to be and authority of the project’s » Making plans – collaborative management care planning » to have teams of manageable size

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We are answering the needs of people who present at the A&E in York with mental health problems by collaborating with York Hospitals Foundation Trust to fund an acute liaison psychiatry service that will improve the speed and quality of assessments there.

A project to remodel recovery services in collaboration with the third sector in Leeds will enable us to close half of the rehabilitation beds. Instead, intensive multidisciplinary support will be available, with additional emphasis on psychologically based treatments The Your Health Matters for people returning to the community. initiative encourages people to Joint working with non-NHS providers achieve healthier lifestyles will improve access to specialist and » to ensure a proper skill mix and supported accommodation so that range of expertise to meet the fewer people will spend unnecessary needs of people who have different time recovering in hospital. problems and are different ages » to manage case-load size. We are proud to be involved, in » to ensure the provision of formal partnership with NHS commissioning supervision and clinical leadership. and Leeds Adult Social Care, in the Your Health Matters initiative, which provides This year we have doubled the number resources for people with learning of patients participating in clinical disabilities, including an animated research projects from 610 to 1185. Our website that encourages people to research department has been enhanced achieve healthier lifestyles and to find by the appointment of an Associate out what services are available to them. Medical Director, so that research directly We have also piloted an award-winning informs our quality improvement activity. project to support people with learning disabilities in specialist supported living During the last year we have completed arrangements, and we are now involved a series of service improvements. in an apprenticeship scheme to help In May 2014 we opened our new people into paid employment. low-security service for women from Yorkshire and Humberside. Its modern Much of our challenge for the next year facilities allow women with mental is to improve our estates. Funding is illness or personality disorder to be available to relocate our Leeds‑based treated closer to their homes. In learning disability services and our partnership with Vale of York CCG and York younger people’s services to Sir Keith Pearson, Chair of North Yorkshire Police we have built high‑quality refurbished buildings that Health Education England a suite for the assessment of people will be safer and meet privacy and dignity standards. In York we are working with ‘By changing patterns of detained under section 136 of the the Vale of York CCG and NHS England working, they are able Mental Health Act, so that the police to transfer inpatient services out of to maximise the training station will no longer be used as a Bootham Park Hospital, a facility that was opportunities available in place of safety in most cases. In Leeds, opened in 1777. Together with partners daytime hours to deliver the existing section 136 service has been extended through the provision we are looking for support to develop better quality training of street triage, to ensure that people a long overdue modern mental health packages, with the aim to who are intoxicated will receive hospital for the City of York. provide better patient care.’ health‑based care promptly.

30 | LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST HEALTHCARE EDITION Lincolnshire Community Health Services NHS Trust

1100 people are treated in our minor injuries units every day A warm welcome from our friendly reception staff incolnshire Community Health Services NHS Trust (LCHS) is seeking foundation trust status. It aims to be the core Lpartner in the delivery of care services across the county. The trust has been on a journey from structural change, which ABOUT US has seen the separation of commissioning and provision, to Lincolnshire Community transformational change, resulting in care closer to home, which Health Services NHS Trust meets the needs of patients. » Serves Lincolnshire, covering 2350 square miles and At LCHS we aim to be different: a population of 723,000 » 2800 staff » We listen, to improve services, and are accountable to local people and patients. » More than 100 patients per » We have strengthened our governance all the way along the chain, from day use our walk-in centre the ward to the board. » Over 160 patients per day » We have a management framework that can deliver highly rated quality services. use our sexual health centres

» We have financial disciplines that promote long-term viability. » 66,000 patients per year » We identify small problems for patients before they become big ones. cared for by complex case managers/community teams Clinical strategy » 3550 people per year cared for in our community Our clinical strategy is focused on meeting the needs of patients, and to achieve hospital beds annually this we have established the role of service integrator. This means that people with health and social care needs will be assessed and have access to all the services » In excess of 100,000 patients they need to promote their health and independence through a single practitioner per year access our working within a local integrated neighbourhood team of GPs and health and social out-of-hours service care professionals.

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long-term vision, the strategy provides models and pathways of working that can be adapted to the changing health needs of local populations and match the aspirations of commissioners.

Community response specification The challenge of delivering services more efficiently while building on quality standards is a common one for provider organisations and commissioners alike. In Lincolnshire, a service specification has Community therapy services are been developed which identifies care available in clinics that can be counted and quality assured. The services delivered by the trust will This means we can monitor how good provide a full range of community care, the care provided is for our patients. from birth to end of life. The clinical strategy outlines a vision of seamless Historically, community nursing services continuity of care for patients. These were based on a core block contact multidisciplinary teams will adopt a which did not contain any level of holistic approach to care, providing GPs clinical detail, a description of the service with a responsive range of pathways delivery model or patient outcomes. to prevent escalation of need and In partnership with the trust’s lead promote self-care. commissioner, LCHS’s approach has » A FULL RANGE OF been to rebuild the contract starting COMMUNITY CARE To improve the health and from the point of referral, identifying the SERVICES independence of patients we need to interventions and support patients need identify deteriorating health earlier. We provide a full range of in any eventuality, through to discharge. Encouraging attendance at GP community care services, practices and keeping a regular eye on For the patient, this: including: elderly people who are housebound » gives equity and equality in care will mean that services are provided for » case management for provision for all patients by providing frail, elderly patients and them earlier, at a lower level of need. a standardised approach across people with one or more This will prevent some illness and injury one of the largest healthcare long-term illnesses, to and be more cost-effective than the communities in the country promote independence current system, where we respond to a » provides increased patient involvement and avoid hospital patient already at crisis point. and empowerment to self-manage admission The financial challenge is significant conditions, as the model of delivery » rehabilitation following in Lincolnshire, and transformational is heavily built around support for stroke, cancer or injury enablers are needed. To deliver self‑care management » community hospital beds the clinical strategy, LCHS is using » improves the level of safe care in local communities for technology to help those staff who delivered in the community GPs to admit patients for work out on the road, improving the » sets expectations for patients from assessment, rehabilitation use of beds and implementing a flexible the beginning of a care episode or respite care workforce to manage staff absence. » gives absolute assurance that the » planned, compassionate staff deployed are the right staff, end-of-life care The clinical strategy has been developed with front-line clinicians, utilising patient with the right skills, competencies » rapid-response urgent feedback and engaging with local and training, through standardising care support services. commissioners. To provide a realistic practice across the county.

32 | LINCOLNSHIRE COMMUNITY HEALTH SERVICES NHS TRUST HEALTHCARE EDITION

For the commissioner, this gives: A number of evidence-based models, including the Department of Health » a clear definition of what is being Long Term Conditions pathway and purchased population profiling, and the NHS » a detailed profile of where Scotland efficiency modelling and investment is used workforce planning models, have been » improved performance indicators used to develop LCHS’s own tool that correspond directly to activity

The formula may be applied to any size Standardising » the ability to improve emergency of population and adjusted to reflect

planning responses the affluence of the local population. practices has » responsive and accurate financial The locality health needs profile is also “ improved “ the reporting used to complete a review of safe » flexibility and variability within the staffing levels for community specialist quality of care contract to address priorities nurses, in particular those managing that patients » adaptation to meet local needs. patients with complex and long‑term conditions and those providing receive In addition, standardising practices end‑of‑life care. has improved the quality of care that patients receive. Revised pathways Managing winter pressures contain specific detail about what level of care activity patients should receive New services have been established to as a minimum, so patients know what provide an integrated care pathway as to expect and staff know what they an alternative to hospital admission, need to be trained to do. Throughout and to provide community-based the development and implementation recovery and rehabilitation to expedite of the new contract, quality and hospital discharge. Services included: performance indicators were reported » a new countywide contact centre to board level. accessed by a single telephone number, providing clinical decision‑making, Just one of the patients treated Effective community staffing capacity management, rapid in their own home by our Assisted Discharge Stroke Service models deployment and signposting There is currently no accredited » rapid-response teams providing workforce planning tool for community assessment and stay-at-home nursing teams. However, there is still interventions an expectation that community NHS » contracted nursing-home beds to trusts will work towards compliance provide specific short-term, intensive with standards and agree safe staffing support for community rehabilitation levels and competencies, provide » additional resources in community briefings to board members, and teams to increase the available provide information to patients and capacity. their visitors. Escalation policies and procedures were A series of multiprofessional workshops agreed, and were implemented at has been held to develop an appropriate times of high demand. formula for baseline safe staffing levels across LCHS community nursing The trust continues to strive towards services. The baseline formula has been Foundation Trust status, but in used to calculate staffing levels, which the meantime we look forward to may then be checked against patient delivering on our aspiration to be at needs, monthly activity data and service the heart of the community. line reporting.

LINCOLNSHIRE COMMUNITY HEALTH SERVICES NHS TRUST | 33 THE PARLIAMENTARY REVIEW Highlighting best practice Central Manchester Clinical Commissioning Group

Dr Mike Eeckelaers in front of the Manchester skyline entral Manchester’s GPs have been fearless in trying new ways of working. This includes seeing patients at Cweekends and in the evening, using new technology, and improving same-day access for urgent cases. These achievements ABOUT US really will have a dramatic, holistic effect on central Manchester Central Manchester Clinical for generations to come, and have only been possible through Commissioning Group the localism we champion so passionately. That localism is the » Chair: Dr Mike Eeckelaers lifeblood of our work. » Serves Ardwick, Chorlton, Fallowfield, Gorton The combined energy of our 34 practices has given doctors the chance to remove (north and south), Hulme, differences in quality of care and outcomes across central Manchester, which has Levenshulme, Longsight, areas of high deprivation. It has also allowed care to be focused on three major Moss Side, Rusholme and long-term conditions – diabetes, heart disease and respiratory illnesses such as Whalley Range chronic obstructive pulmonary disease (COPD). » Serves a population of more We are also redesigning mental health care in Manchester, and are playing a greater than 200,000, around a role in the improvement of cancer care. This has then set the scene for the wider third of which are from evolution needed to move more care away from hospitals and into the community. the black and ethnic That evolution started even before the organisation was formally constituted, when minority (BME) group; we were chosen as a Pathfinder, or trial area, to test how a clinical commissioning large number of students; group (CCG) could operate. 90 languages spoken

» 34 practices From the outset we were very clear that our doctors’ views on both their patch and their patients would shape the future of services in this area. That conviction has been the foundation for all our achievements since then. It is also why it is vital that, as the chair of the CCG, I spend at least half my time in practice as a working GP on this patch and half my time in my commissioning role.

34 | CENTRAL MANCHESTER CLINICAL COMMISSIONING GROUP HEALTHCARE EDITION

First and foremost I am a doctor. I am options around the management managerially-savvy, but I am not a of conditions that had previously business expert. However, I am extremely been managed in hospital. A natural fortunate to have a chief officer, development from here will be Ian Williamson, who has the strong to bring consultants out to the leadership to translate clinical needs into community to support GPs with sound business plans that have kept specialist interests. us on budget for three years. This also » Supporting vulnerable people The key to reminds me of Professor Chris Ham’s such the homeless, people in care dictum – speaking as head of The King’s homes and dementia patients. commissioning Fund – that the key to commissioning This puts the GP at the heart of the success is ‘a clinically intelligent manager patient’s care, coordinating all the “ success is with a managerially intelligent clinician’. different health and social needs. a ‘clinically For example, we are trialling a

In our case we both also live in the city we system where one of our practices is represent, and local knowledge cannot intelligent registering homeless patients straight and should never be underestimated. Nor “ from hospital so that they can be manager with should the motivation of our doctors to referred to ongoing services. improve and develop services at a time a managerially of unprecedented hardship. Our Demonstrator started in December intelligent 2013, and by May 2014 more than Last year we bid for funding from NHS 3000 patients had been seen due to clinician’ England for programmes that could the additional hours and availability. improve primary care and make a More than a fifth of patients surveyed difference to the community. These are said that they would have gone to A&E known as Demonstrator sites. Central if this service had not been in place. In Manchester’s Demonstrator, which addition, there has been a significant received £719,000 funding, focused on drop of almost 25% of Central four main areas: Manchester patients attending the walk-in centre from December 2013 to » Improving access and increasing Moss Side-based GP Dr Sirfraz availability of primary care. We March 2014, compared with the same Hussain uses video calls as a way set up four host practices to act as time the year before. of seeing patients who find it difficult to come into the surgery hubs across the CCG area offering We now want to use this success to appointments up to 8 p.m. and for drive our role in another key strand three hours on Saturday and Sunday. of city-wide work called Living Longer Our practices also agreed to deliver Living Better, which focuses on out new standards around urgent care of hospital health and social care. so that, for example, people with Working with the city council, the emergency needs are seen within three acute trusts, the mental health two hours. Some of our practices are trust and Manchester’s three CCGs, also offering Skype consultations. the aim is provide a joined-up system » Support and management for that blends social, mental and physical people with long-term conditions. well-being. It is a bold ambition that Our doctors and nurses have been gives patients and their carers more trained to manage certain conditions chance to take control of treatment such as heart disease and diabetes in through home-based care that fits the community, to keep patients well in with work and family life. It will and out of hospital. also reduce the demand on hospital » Specialist primary care provided services, which in turn will help Greater closer to home. Advice lines are Manchester to transform and redesign now in operation with hospital hospital services to make them safe specialists to allow our GPs to discuss and sustainable in the future.

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Increase GP availability: • 8 a.m. to 8 p.m. weekdays, 3 hours Saturdays Every patient with a long-term condition recieves and Sundays high-quality local care – initial focus on diabetes, • Emergency GP care within 2 hours heart failure and COPD • Urgent GP care within 6 hours As a patient I will have consistent high-quality As a patient I will have Long-term local support and expert increased access to a GP Access conditions care to manage Consistent my long-term illness high-quality care As a patient I will be involved in my own care, As a patient I will receive Specialist Patient especially if I live in a care specialist primary care primary care voice home, have dementia, am close to where I live homeless or in my last days

Specialist care provided closer to home: Vulnerable people get their voice heard. Enhanced • Initial focus on pain management care for people in care homes, those with dementia • Specialist advice for GPs to avoid unnecessary and the homeless referrals and prescribing

Central Manchester CCG’s Demonstrator project As we now move into a new era to be mindful that we in the NHS should dominated and enhanced by be responsible employers in our area – partnership working, we have seen our biggest hospital trust alone employs that collaboration – and our role within around 10,000 people. it – feed directly into the Health and Wellbeing Board, which protects the Finally, localism and the freedom to most vulnerable people in Manchester. make our own decisions must stay at This has given us the belief that as a the very heart of our work in central CCG we can and will help to change Manchester. Our Demonstrator project health outcomes for patients in the city. has shown how the right funding, coupled with the tenacity of our GPs Beyond the NHS we can also see the and the vision of the CCG, can effect effect of our work in the wider economy, the changes needed to improve local as we view work as a health outcome. services in our diverse population. Our GPs see the direct link between work and staying well. We know that Money spent on projects like this has when people are in work but off sick started the wheels of change to drive they can fall into unemployment. So, our bigger health dividends for the future. doctors can now refer patients into a service that will help with any obstacles to getting back to work. We also need

»BIOGRAPHY

Dr Mike Eeckelaers Dr Mike Eeckelaers is Chair of Central Manchester CCG and a partner GP at West Gorton Medical Centre. He has been a GP for 27 years and has over 20 years of commissioning experience, from GP fundholding through to primary care trusts, practice-based commissioning and now the CCGs.

36 | CENTRAL MANCHESTER CLINICAL COMMISSIONING GROUP HEALTHCARE EDITION NHS West Hampshire Clinical Commissioning Group

Dr Tim Thurston, Director for Innovations and Membership, speaking at a Strategy Development Workshop

Dr Sarah Schofield, Clinical Chair s one of the largest clinical commissioning groups (CCGs) in England, West Hampshire has embraced the NHS Areforms and the challenges these have presented. Our watchword is ‘innovation’, which is driving a dynamic and patient‑focused organisation that supports staff and providers ABOUT US to deliver high standards of care built on the needs of our NHS West Hampshire local communities. Clinical Commissioning Group

GPs feature predominantly on our leadership team, which, together with professional » Covers 800 square miles managers, is committed to improving local health services. We have five elected GP of Hampshire, ranging from board members and six GP locality leads, each covering a different geographical Whitchurch and Andover in area, who work with our 11 clinical directors (also practising GPs) to ensure that the north to Fordingbridge services are developed to reflect local needs. We are unlike many CCGs in that our in the west and Lymington in board has an equal mix of female and male members, including myself, Dr Sarah the south Schofield, Clinical Chair, and Heather Hauschild, Chief Officer. » Has 51 GP practices » Serves a population of Innovation and transformation nearly 546,000 Our commitment to innovation has supported the national drive for transformation, » Supports over 136,000 which was the buzzword for 2013. Headlined as a ‘call to action’, and fronted by national people living in rural leaders, the health system was challenged to deal with the pressures that threaten communities to overwhelm it. These include ever-growing demand, an ageing population and rising rates of long-term conditions, coupled with an increasing range of expensive treatment. » Has identified 144,000 people with a long-term Much has been said about these challenges, and we have set out to address them condition creatively. Locally, one of our GP board members, Dr Tim Thurston, is responsible for driving this agenda forward, and we have secured regional innovation funding to

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momentum. This has formed a core focus for West Hampshire CCG. As lead commissioners of adult mental health services for the five CCGs in Hampshire, we have successfully delivered a number of improvements to support those in our community who need these services. This includes initiatives such as hospital- at-home care for adults, and associated services offered in five health and well-being community centres. We have funded additional mental health nurses to work with emergency departments and medical assessment units, and Paul Turner, Associate Director, Vulnerable Adults, received the have successfully retendered Improving Chair’s Award for Leadership for Access to Psychological Therapies his leadership of our Continuing support changes within our organisation. services. Together with Hampshire Health Care and Funded Nursing County Council, we have also supported Care teams at Fareham Health This funding will enable us to ensure Centre over 2013–2014. that innovation is at the heart of our those with mental health needs who are Pictured here with Heather approach, and we are using a dedicated involved in the criminal justice system. Hauschild, Chief Officer, and This work will continue, in collaboration Dr Sarah Schofield, Clinical Chair software system to support this. with providers and other commissioners We have worked with one of our local in Hampshire, to reduce variability across providers to fund the recruitment of GP mental health services, and deliver fellows (non-practice-based GPs) into a improved outcomes for patients through unique role that identifies and supports services that provide timely, safe and those people who are most at risk of poor effective care. health and hospital admission. Through early identification, and by arranging extra health and social care sooner, the People-powered health » OUR DEDICATED fellows work across the health system to A key feature of West Hampshire INNOVATION prevent illnesses becoming crises, helping CCG is our commitment to ensuring SOFTWARE SYSTEM people remain at home and supporting that patients, carers and the public patients to return home earlier after are involved in shaping services. This All staff will be able to use spending time in hospital. is particularly relevant to our work our dedicated software on long-term conditions, where system to share innovative We are also working with Health ever‑increasing numbers of patients ideas, which we can take Education Wessex to review the shape have affected the way in which forward for development of our workforce and how best we can clinicians are caring for and treating within our organisation. As meet the needs of our local population patients, with shared responsibility the only CCG to have this through innovative approaches. This between them a growing focus. system, we are very excited includes exploring ways in which Developing and embedding approaches about the opportunities future doctors can undertake more to encourage self-management, it presents, and will be of their training in the community, to which need to begin at the start of involving our partners and support our commitment to delivering treatment for long‑term conditions, residents in its use. out‑of‑hospital care. are vital, and we are dedicated to driving improvement in this area. In particular, the CCG has worked with Driving equity of access patients, carers and the voluntary sector ‘Parity of esteem for mental and physical on shaping and enhancing diabetes health’ has become a much heard services – figures published in March phrase as the commitment to drive 2014 by Public Health England indicate equity of access has gained national a fall of nearly a fifth in diabetes‑related

38 | NHS WEST HAMPSHIRE CLINICAL COMMISSIONING GROUP HEALTHCARE EDITION major amputations in West Hampshire made headlines with his proposals for over the three years 2010–2013. Work CCGs to be co-commissioners of primary continues in this area to encourage care. We welcome this opportunity. better self‑care and to increase the Taking this forward, however, means provision of community‑based foot care. careful consideration of the details and ensuring we have open and transparent Helping people to live well with dementia arrangements in place for making A key feature of is a priority and, in partnership with decisions. With six geographical areas other organisations, we are providing making up West Hampshire CCG, we West Hampshire high-quality care throughout West will progress this in a way that takes local Hampshire. In particular, we have “ CCG is our needs into account and delivers improved worked with Southern Health NHS care for our patients. commitment to Foundation Trust to increase dementia diagnosis at GP practice level, establish Much has already been undertaken by ensuring that a team of specialised nurses to visit the CCG on work associated with the nursing homes, improve psychiatric Better Care Fund to facilitate better patients, carers liaison and access to memory services, health outcomes for our patients through and the public“ and set up dementia advisory services more integrated health and social care. and crisis response functions. Together with neighbouring CCGs and are involved Hampshire County Council, we have in shaping Shining a light adopted a phased implementation to commissioning jointly all out‑of‑hospital services Last year there were a number of care in the next five years. Although a reviews into and reports of system major challenge, this will bring a range failings across the NHS, which have of benefits for patients that include had far-reaching implications. The independence and better outcomes, Mid Staffordshire enquiry, the Keogh people receiving the right care in the Mortality Review and Hard Truths: The right place and at the right time, new Journey to Putting Patients First have roles for staff with more flexible working, led to radical plans for prioritising care, named accountable GPs, hospitals improving transparency, and ensuring Speakers at our 2014 annual focusing on the most sick and at risk to meeting clear action and accountability to tackle support recovery at home, and health poor care, which we are embracing. services working closer with home care As commissioners, we have a vital role workers and carers. in driving forward these changes, and ensuring that commissioned services Seizing the day offer a safe and dignified environment in which to treat and care for patients. The challenges continue, but the We have championed this much needed possibilities are endless and the change and, in the past year, have opportunities great. We truly believe taken part in a Care Quality Commission that the NHS is much better positioned type review at a local provider to bring a than ever before to shape and improve commissioner perspective. This broader further the health of its communities, assurance approach proved particularly and CCGs are best placed to do successful, and we are now in talks this. As GPs we are harnessing this with other providers to roll this out as invaluable insight to empower our best practice. patients and change the shape of the NHS. This is supported by our CCG’s innovative and dynamic leaders, Change ahead who, in partnership with local patients, In recent months, Simon Stevens, the are embracing these challenges. chief executive of NHS England, has

NHS WEST HAMPSHIRE CLINICAL COMMISSIONING GROUP | 39 THE PARLIAMENTARY REVIEW Highlighting best practice NHS Dorset Clinical Commissioning Group

Tim Goodson, Chief Officer (left), and Dr Forbes Watson, Chair Clinical leadership and patient involvement are at the heart of our work HS Dorset Clinical Commissioning Group (CCG) is a membership organisation comprising 100 GP practices Nthroughout the county, which are grouped into 13 geographical localities, with a registered population of ABOUT US around 766,000. This makes us the third largest CCG in England

NHS Dorset Clinical in terms of population, and with a commissioning budget of Commissioning Group £947 million we are the second largest in financial terms. We have a governing body and our own constitution which sets out » Serves the county of Dorset – large conurbations, small how the organisation works. market towns, rural villages and the Jurassic Coast We know the NHS has significant financial challenges. Here in Dorset our » Serves a population of around demography and life expectancy means we will feel the impact of caring for an 766,000 ageing population. The attractiveness of Dorset means many people choose to » 100 GP practices grouped into retire here. Twenty-five per cent of our residents are over 65, compared with 16% 13 geographical localities nationally, and we have seen a 40% growth in the number of over-90s in a decade, rising from 4000 to 5600. » 25% of the population is over 65, and 5600 residents are We must be confident in where to spend our money and how to spend it well. That over 90 means acquiring first-class clinical and management skills and developing a creative » Budget: £947 million and innovative vision for the future. Some of the projects we are proud of are: » Installing fitness equipment in public parks, with free access for everyone, to help tackle obesity and improve health. » Supporting a study to see whether pedal power can ease the stiffness and pain of osteoarthritis. Volunteers sign up to an eight-week education and exercise cycling programme which, if effective, may be rolled out nationally.

40 | NHS DORSET CLINICAL COMMISSIONING GROUP HEALTHCARE EDITION

» Checking for an irregular pulse put them at the heart of local health when people have their flu jabs services. In preparation for these to spot atrial fibrillation (a risk significant changes, we provided a factor for stroke), then offering Leadership Development Programme an electrocardiogram and starting to enable our clinicians to become preventive treatment if necessary. confident in their new role as » RECOGNITION FOR » Using Facebook and online polls commissioners, leading local health OUR WORK to ask new mothers how we priorities and making the best use could improve maternity services, of resources. This programme was » A project that used a project that reached the finals shortlisted for the inaugural Guardian Facebook and online of the NHS England Excellence in Healthcare Innovation Awards. polls to ask new mothers Participation Awards. how we could improve GPs now head up our seven Clinical maternity services reached » Working with local health partners Commissioning Programmes (CCPs), the finals of the NHS to launch Drinkheads, a hard‑hitting each of which focuses on a different England Excellence in campaign to alert parents to the area of health. For example, Clinical Participation Awards. dangers of drinking alcohol when Chair of the Mental Health and » Our Leadership they are looking after young children. Learning Disabilities CCP is GP Dr Paul Development Programme French, who says: For this relatively modest investment was shortlisted for the of time and money, we may well reap ‘One of the principal aims of inaugural Guardian significant financial and health rewards. this CCP team is to ensure that Healthcare Innovation The projects are certainly an important people with a mental illness Awards. part of our mission: ‘Supporting people or condition are assessed and » The Christchurch in Dorset to lead healthier lives’. treated by services that are on Health Network won Obesity, for example, is implicated a par with those available for a prestigious award as in many health problems, including people with physical ill health. the best example of a diabetes, heart disease and joint This is called “parity of esteem”.’ ‘practice working with its community to improve problems. By giving people the To achieve this, the CCP works closely health’ in the NHS Alliance opportunity to have some free fun we with the West Dorset Mental Health Acorn Awards. may help them to avoid these diseases Forum, an independent charity run in later life. by people with experience of mental Similarly, the pilot atrial fibrillation project health problems. Its chief executive cost relatively little but it was estimated Becky Aldridge says: that every £1 spent could save the NHS ‘Being part of the CCP team £220 in the long run. More than 6000 and having a voice within The fitness equipment we patients were screened for an irregular installed in Blandford means pulse in our flu clinics. More than 20 people can work out for free in are now on medication to lower the risk their local park of stroke, which can be a devastating disease for the patient and costly for the NHS. One patient to have benefited is 86-year-old Peggy Hansford, who is now receiving treatment and being monitored at her GP surgery. She says: ‘I feel very supported. They are very good – almost like members of my family.’

Making an impact Our clinicians have embraced with enthusiasm the NHS reforms that

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commissioning projects gives us networks throughout our area that feed the opportunity to act as a critical into our Health Involvement Network, friend and to bring the customer which has over 2000 members. and patient experience to the heart of the CCP’s business.’ Difficult challenges ahead Information from our engagement Supporting our communities activities has also helped us to draw GPs also lead our 13 localities, each up our strategy. We will focus on three covering a different area of Dorset. transformational programmes: In a county as varied as ours, with its spectacular Jurassic Coast, traditional » Better Together – transforming rural villages, small market towns and health and social care across Dorset the large conurbations of Bournemouth to deliver sustainable improvements and Poole and Weymouth, Portland in health and care through and Dorchester, the lifestyles and health person‑centred, outcome-focused, needs of our 766,000 residents may vary preventive, coordinated care. significantly according to where they live. » Clinical Services Review – looking at clinical services right across the To ensure that we learn from and take health and social care system to account of their differing views, our ensure they are sustainable and Our transformational programmes GP locality chairs are also members future-proof. will ensure we build a sustainable of the CCG’s governing body, where » Urgent Care Review – transforming healthcare system their extensive local knowledge is care services across Dorset by invaluable when planning for the future. aligning and simplifying pathways Gathering views, listening to people and integrating technologies. and feeding back this information to our commissioning teams is a really These programmes are interlinked, and important part of today’s NHS. will be delivered in partnership with our three local authorities and the four Patient and public involvement main NHS foundation trusts in Dorset, with whom we have established strong We have run a range of public The lifestyles working relationships. engagement activities to inform our and health plans. In our first year this included Through these programmes we will “ needs of The Big Ask, which we launched with look for further opportunities to other health colleagues. We gathered integrate health and social care, and to

our 766,000 views about our health services and ensure, where possible, that all services suggestions as to how they could be are provided as close to home as

residents may improved. Over 6000 responses were possible and in the community. received, and this primary research is vary significantly“ underpinning several projects. All NHS organisations are facing a according to scenario of an ageing population but A Christchurch GP practice won a this will perhaps affect us more here where they prestigious award as the best example of in Dorset due to the demography and a ‘practice working with its community life expectancy of our population. We live to improve health’ in the NHS face this future, where we are going Alliance Acorn Awards. It established to have to make difficult decisions, a Christchurch Health Network, with our core values at the forefront linking local authorities, third-sector of our minds – honest, caring, organisations and others to feed back to responsible, collaborative, responsive the CCG’s Christchurch Locality Group. and courageous. This is just one of a number of health

42 | NHS DORSET CLINICAL COMMISSIONING GROUP HEALTHCARE EDITION Bury Clinical Commissioning Group

We are committed to working with partners to join up health and social care services in the future

Dr Kiran Patel, Chair and Clinical Lead robably the biggest single achievement of Bury Clinical Commissioning Group (CCG) to date has been the work Pundertaken to widen access to primary care across the borough. The work was initially piloted in Radcliffe, one of the Greater Manchester primary care demonstrator sites, and ABOUT US has culminated in the Bury GP Federation being successful in Bury Clinical securing in excess of £2.7 million from the Prime Minister’s Commissioning Group Challenge Fund. In Bury we are unusual in that, in addition to active involvement of the GPs in our member practices, we also » 33 member practices have active engagement from a number of pharmacists. This » Serves a population of over has enabled Bury CCG to make progress in the development of 190,000 patients a number of clinical pathways, treating minor ailments through » A budget of around pharmacists and optometrists. £220 million

The seeds of our success were germinated in 2012–2013, when the CCG supported and facilitated a number of member practices in creating the Bury GP Federation, in order to enable us to provide enhanced primary care services on a greater scale than individual practices could achieve alone. The federation has gained increased traction within Bury, and over 90% of member practices are now also members of the federation. The development of this organisation was a major factor in a successful bid to the Prime Minister’s Challenge Fund.

This bid built on the vision of a number of GPs in Bury who are shaping the CCG’s urgent-care strategy. They proposed that increasing access to primary care to be available from 8 a.m. to 8 p.m. on weekdays and from 8 a.m. to 6 p.m. during

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weekends and bank holidays would delivery. The aim was to target funds enable more routine appointments to on short-term pilot trials or schemes be offered in these extended hours. that required pump priming and would This would also be more convenient for change ways of working. Successful the working public and, in turn, would schemes were prioritised according make available urgent appointments to their ability to improve patient in both routine weekday hours and outcomes, encourage innovation the new extended hours. A key factor and inform future commissioning has been Bury’s IT strategy for primary intentions. To support these aims, we care, whereby all practices are linked agreed robust monitoring requirements through the same IT system, which for all successful schemes so that at the enables patient records to be shared end of the pilot we could assess the across practices. This has been essential success of the delivery of outcomes. for us to widen access to primary care. An example of a successful project A key focus of the CCG in 2013–2014 under this initiative was an evaluation of has been to improve primary care point-of-care testing in a local acute A&E support to nursing homes, with a view department. It was anticipated that the to both improving the quality of care use of point-of-care testing technology When serving as Prime Minister, for residents in the homes and to avoid would enable the timely risk stratification Sir Robert Peel, a native of Bury, emergency admissions to local hospitals of patients with chest pain and a commissioned a report asking unless they are absolutely necessary. provisional diagnosis of acute coronary local doctors for information, This has been achieved by partnering syndrome. This would allow discharge with a view to improving public health matters in the town each nursing home with a GP practice from the emergency department of responsible for providing clinical care to those patients deemed low risk and all the home’s residents. suitable for further investigation as an outpatient, thus avoiding a hospital This partnership working has enabled admission and improving the quality GP practices to support nursing home of care for patients. Early results have Our vision staff to deal with complex end-of-life shown a positive shift to achieving the ‘Our vision is to continually care for residents without resorting to planned outcomes. improve Bury’s Health and calling for an emergency ambulance, Wellbeing by listening to you leading to an inappropriate hospital Another unusual approach taken by and working together across admission. A further benefit of this the CCG has been the creation of a boundaries.’ initiative is that potential quality of Patient Cabinet, the members of which care issues, relating to the handling seek to reflect the views and needs Our values of prescribed medicines and pressure of patients in Bury, thereby better » To be inclusive and sores, in some homes have been enabling us to shape the changes we transparent about the picked up and addressed early, make to clinical pathways. decisions we make. because clinicians were seeing all the patients in a home. A number of We have been able to achieve all this » To challenge inequalities CCGs across Greater Manchester are against a background of a hugely through partnership interested in adopting this approach. challenging financial position. In working. In connection with this, Bury CCG is 2010–2011 the then Bury Primary » To be bold, inclusive and the best performing CCG in Greater Care Trust had a recurrent deficit of supportive. Manchester in helping the residents to £16.5 million. Over the past three » To value everyone. choose where they want to die. years, due primarily to strict adherence » To listen and learn. to agreed clinical referral protocols for In 2013 we issued an invitation to elective care and improved prescribing » To secure people-centred, teams, organisations and consortiums by clinicians, this recurrent deficit has clinically effective, efficient from the NHS, the third sector, and been cleared. This is despite the fact and sustainable care. independent providers to bid for funds that NHS England recognises that Bury to support innovation in health service CCG is underfunded by £20 million

44 | BURY CLINICAL COMMISSIONING GROUP HEALTHCARE EDITION per year, the most underfunded CCG in the north of England. It is through the support and commitment of all member practices that we have been able to achieve this position.

Aspirations include the continued development of strong partnership arrangements with the local authority in implementing integrated care solutions, including social care, and the increased access to primary care. This will enable Bury CCG is unusual in that it Bury CCG to engage with the public has the active involvement of a towards the end of 2014 to describe number of pharmacists how they can access the new integrated of the public is critical to the successful health and social care system in Bury. implementation of the CCG’s vision. This engagement with and education

»OUR DEVELOPMENT AND OBJECTIVES

During the last year, we have developed in our role as the lead health commissioning organisation for Bury. Examples of performance against our objectives include:

» An integrated diabetes service was established, bringing hospital- and community-based care together. » An inhaler education programme was rolled out across Bury, offered to all healthcare professionals involved in the care of patients with asthma, with a view to improving asthma management and care. Engagement » We launched a minor eye conditions self-referral scheme to benefit patients experiencing a range of minor eye conditions. with and » Bury has done well in terms of supporting patients to die in their preferred “ education of

place of care, and we are currently reviewing the end-of-life pathway. the public is The following initiatives relate to our commitment to parity of esteem:

» A learning disabilities ‘champion’ has been identified in each general practice, critical to the and mechanisms are in place to ensure that all patients with a learning successful“ disability eligible for an NHS health check are invited for one. » A joint Mental Health Strategy and Action Plan has been developed with Bury implementation Council, with a view to improving mental health and emotional well-being. of the CCG’s » A joint Dementia Strategy and Action Plan has been developed. Bury is piloting a Dementia Advisor Service delivered by the Alzheimer’s Society, and we funded vision an innovative project working with carers and patients within BME (black and minority ethnic) communities with a view to improving diagnosis rates. » The service for autistic spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) has been redesigned to provide patients with a seamless coordinated service, leading to a better experience for young people and their families. Furthermore, a service for patients aged 18 and over has also been commissioned. » The Child and Adolescent Mental Health Service (CAMHS) has been reviewed and now includes a single point of referral for mental health services for children and young people.

BURY CLINICAL COMMISSIONING GROUP | 45 THE PARLIAMENTARY REVIEW Highlighting best practice NHS Aylesbury Vale Clinical Commissioning Group

The Aylesbury Vale CCG Clinical Executive – eight GPs around the table Dr Graham Jackson still works over half the week in clinical practice HS Aylesbury Vale Clinical Commissioning Group is keen to embrace innovative thinking with the help of Nnew technology. In order to respond better to individual patient’s needs, we know we must structure ourselves in a way ABOUT US that really enables us to engage with local people and come to terms with their needs. NHS Aylesbury Vale Clinical Commissioning Group

» Chair: Dr Graham Jackson Our three localities of member practice populations, grouped around the main towns of Aylesbury, Buckingham and Haddenham, provide geographic focus. » Chief Officer: Louise Patten They enable us to dig into the details about the specific health and social RGN BSc DN MBA demographics, the community assets that are available and the specific well‑being » Chief Finance Officer: challenges for each community. Each clinical locality leader ensures that we Robert Majilton maintain an approach which remains very close to the population he or she is serving. » Serves Princes Risborough, Thame, Aylesbury, Across the whole age spectrum we are working on new ways to tackle inequalities Buckingham and across and improve health and well-being. Last year we developed initiatives that will bring north Buckinghamshire long-term benefits and improve the health of our whole population. Serves a population of over » In terms of our youngest population, we have a project in central Aylesbury that 200,000 seeks to improve the skills and confidence of parents managing common childhood » 21 GP practices conditions. Having mapped the neighbourhoods with high A&E attendance rates for the under‑fives, we were able to target specific areas in which we have been running an educational outreach programme. This links our GPs to children’s centres and developing the confidence of our parents. We are also using social media and a locally developed web-based resource to manage common childhood illnesses that signpost to the most appropriate services.

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We recognise the need to engage and then they give you tablets actively with our youth population, not and inhalers or whatever and only for their specific needs but also then you go away but there is because of their ability to influence family more to the whole person, and members. This year we ran a competition before this group started you for schools in the Aylesbury Vale area to were on your own, or you felt design posters and videos, encouraging you were on your own – there appropriate use of urgent‑care services. was nobody to help you and The response was really positive; the mentally it impacts a great deal.’ We are working classroom discussions and assemblies (Patient with chronic obstructive on new ways led to significant engagement with the pulmonary disease speaking pressures on urgent-care services and about the Live Well project) “ to tackle how to signpost people to use these more appropriately. During this year, working closely with inequalities “ our Buckinghamshire County Council Healthwatch, our local media and staff partners, we have introduced Flo, a and improve from the local emergency department text messaging system, supported by health and helped to judge the competition. Our clinically approved protocols, to help award ceremony ensured every child people with newly identified long-term well-being involved was given a certificate of conditions to monitor and self-manage participation and the opportunity to their care. come up on stage to be recognised for their efforts. We are using the In the elderly, dementia is a condition materials designed by the children in that affects the whole family, and our winter messaging campaigns, and places significant stress on individuals. look forward to continuing to work In Aylesbury Vale, the number closely with the adults of the future. of people living with dementia is expected to rise significantly by 2020. For our adult population, we have The challenge is to encourage our concentrated on helping people with population to achieve early diagnosis, long-term conditions achieve a higher in order to offer early planning and quality of life, by taking more control support to people with dementia, their over the management of their health. families and carers. Live Well is a community based, Louise Patten, Chief Officer, integrated service for people with with some of the winners of our one or more long-term conditions. schools design competition This new service offers extra support to patients who are not coping with the management of their long-term condition, through the integration of psychological therapies, physical exercise and nutrition advice. Live Well is based at the patient’s GP practice and accessed by their GP or nurse through the use of risk stratification data, multidisciplinary team meetings, and via referral from other services. The shared access to the patient record and regular multidisciplinary meetings support onward care planning.

‘You go to the doctors and they give you devastating news

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In 2013–2014 we have continued to »CASE STUDY work with our partners such as Age UK and the Alzheimer’s Society to improve Mrs G, a 55-year-old woman newly our person-centred services, available to diagnosed with hypertension people with dementia and their families, requires frequent blood pressure through introducing memory assessment readings until her long-term Our work closer to home. The memory advice condition becomes more stable. service gives advice to patients with Naturally, she is anxious about to date has dementia and their families, acting as her condition: however, she has the ‘front door’ to provide support, been trained in the use of a home “ taught us the monitoring assistive technology ensuring that the most appropriate importance services and advice are provided. system and she is able to text her

blood pressure readings directly of focusing We have a long-established dedicated to her GP surgery. This initiative

Dementia Primary Care Worker, who has reduced Mrs G’s anxiety and on our links closely with our GP surgeries and the inconvenience of having to populations“ local memory clinics. This year we have make regular visits to the surgery, enhanced our earlier diagnosis rates by through boosting her confidence and identifying using a mobile cognitive assessment to self-manage her condition. tool, which has broadened the range their specific of locations in which people can access of focusing on our populations and this initial assessment. needs identifying their specific needs. This Looking to the future, we have enables us to engage and respond with significant financial challenges ahead solutions that work for our patients, that will require radical redesign of which we can then build on in order to our commissioned services. Our work develop system-wide improvement. to date has taught us the importance

A selection of the entries to our schools design competition

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Europe controversy resurfaces yet again

Backbenchers, led by John Baron, a rebel on a variety of issues, put down an amendment regretting the lack of a referendum Bill in the new legislative programme. This was the annual debate on the government’s programme of new laws for the coming year; and an amendment regretting its contents is usually a matter for opposition rather than government MPs. The Baron amendment was made possible by a convention-stretching ruling by Speaker John Bercow, who decided that, in addition to the usual two amendments granted to the official opposition Tory backbench discontent and the one allowed for the biggest over Britain’s relationship with the EU boiled over in minor party, he would also allow the the debate on the 2013 The intricate battle over Britain’s backbench amendment. Queen’s Speech relationship with the EU, which was to The pro-EU Liberal Democrats were run through the whole parliamentary never going to permit a referendum year, began in the debate on the Bill in the coalition government’s 2013 Queen’s Speech. Ever since 81 programme, but the backbench uprising Conservative MPs defied a three-line forced David Cameron to permit an whip to vote for a motion calling for a unprecedented free vote, and promise referendum on Britain’s membership of to back a private members’ Bill to hold the EU in October 2011, Tory backbench a referendum in 2017. discontent had been simmering. But Deputy Prime Minister this was the moment when it boiled John Baron said MPs on all sides Nick Clegg came under over and changed party policy. believed the time had now come to heavy fire from Eurosceptic Conservatives over an give the British people a say – adding, election leaflet quoting during a fractious exchange with the him as promising an shadow chancellor Ed Balls, that if the in–out referendum referendum was held tomorrow he would vote to leave. But that could change if the Prime Minister succeeded in negotiating a new relationship based ‘on trade, not politics’.

The debate was prefaced by exchanges at Prime Minister’s Question Time, where the Deputy Prime Minister Nick Clegg was standing in for David Cameron. Mr Clegg came under heavy

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The government had already legislated to guarantee a referendum when the next major fire from Eurosceptic Conservatives, Eurosceptic colleague, Bernard Jenkin, change in EU rules is including Edward Leigh, who intervened: ‘I cannot imagine that the proposed produced a Lib Dem election leaflet EU would want to cut itself off from quoting Mr Clegg promising an the British market by getting into a in–out referendum. Was the Nick trade war … May I also point out that Clegg quoted there an imposter or a we export more to the rest of the hypocrite? Mr Clegg retorted that the world than to the EU?’ government had already legislated to guarantee a referendum when In the end, the Conservative the next major change in EU rules is leadership told their ministers to proposed, which made it a question abstain, and allowed backbenchers of when, not if, there would be a free vote. The results were striking: a vote. 116 Conservative MPs – the vast majority of non‑ministers – backed When the Queen’s Speech debate the amendment. Along with a resumed, there were several exchanges smattering of non-Tories, that of friendly fire between Conservative produced 130 votes in favour – but MPs. The chair of the Foreign Affairs Labour and the Lib Dems mustered Select Committee, Richard Ottaway, 277 against. Technically, this was not a attacked the idea that Britain could ‘rebellion’, but it is unprecedented for withdraw and seek a new trade-only a government party to allow its MPs relationship with the EU, along the to abstain in a vote over its Queen’s lines of Norway and Switzerland. Speech, let alone back an amendment. ‘Norway and Switzerland do not call the shots,’ he said. ‘They pay The Prime Minister declared himself billions every year for access to the ‘relaxed’ about the outcome, and single market, and Switzerland has the following day James Wharton, been forced into renegotiation.’ A the youngest MP, topped the annual

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ballot – a sort of raffle – for the right to bring in a referendum Bill – and the EU bring in a private members’ Bill. Within issue reverberated through the rest of the hour he announced he would the year.

Conservatives legislate for an EU referendum

to delaying tactics, which could use up the available debating time and so defeat the Bill without an open vote.

Until he topped the private members’ Bill ballot, James Wharton had been a low-profile figure in the Commons, but he launched his Bill with aplomb: He said the EU was a very different institution from the Common Market Britain had joined: ‘No one knows where it will be in a few years. It is the right approach that, rather than rush Prime Minister David headlong now to make a decision, Cameron with James we should negotiate to get the right Wharton MP The sequel to the unprecedented deal and to understand what future Queen’s Speech amendment was the membership of the European Union intricate battle over James Wharton’s would mean. Whatever the result of private members’ Bill. Its immediate that process … ultimately it must be put effect was to provide a strategy around to the British people so that they can which Conservative MPs could unify, choose whether to renew their consent which was popular with party members to membership or to withdraw it.’ and provided a counter to UKIP. Its A couple of interventions gave a flavour Achilles heel was that the Bill lacked of events to come. Labour procedure the procedural protection enjoyed by expert Thomas Docherty asked whether government legislation. There was no citizens in Gibraltar would have a vote, guillotine on debate, and no time limits but Mr Wharton sensed a trap, warning for speeches – making it vulnerable that the larger and more complex Simon Hughes MP the Bill became, the greater were the opportunities for opponents to wreck it.

Another theme was the coalition’s yawning Euro-divide. Many of the Conservative MPs wore badges showing a Lib Dem election leaflet featuring Nick Clegg promising an in–out referendum. When the senior Lib Dem Simon Hughes reminded MPs that the coalition has already legislated for a referendum on the next major treaty change, he was jeered.

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Mr Wharton accused the Lib Dems of hour without saying how Labour would ‘changing their position as the wind vote. ‘Rarely in this house has a speech blows’. accusing others of causing uncertainty been so totally shrouded in uncertainty Shadow foreign secretary Douglas itself,’ he added. Alexander dismissed the Bill as a stunt prompted by the electoral threat of The Bill was given its second reading by UKIP and an internal threat to David 304 votes to none – and later survived Cameron’s leadership. It would two and a half gruelling days of threaten jobs by raising a question report‑stage debate unscathed. But its about the UK’s EU membership. But he slow passage meant that the Bill was was mocked by the foreign secretary always likely to run out of time in the William Hague, who noted that Lords, where a posse of determined Mr Alexander had spoken for half an pro-EU peers lay in wait.

The referendum bill runs aground in the Lords

The final act of the referendum Bill drama came after two long Fridays of detailed debate in the House of Lords, conducted at a snail’s pace. It was not a direct vote against the Bill but an implicit one, in which peers voted to close down their committee-stage debate rather than continue it into the small hours of Saturday morning.

By the time the Labour peer Lord Lipsey moved his motion to end the day’s debate, it was clear that there was no prospect of peers dealing with all the amendments before them. There were 76 amendments in all, mostly from opponents of a referendum, on subjects varying from requiring a minimum percentage of the electorate – 25%, 40% or 50% – to vote in order to make the result binding, to allowing British expats in EU countries to vote, to requiring an all-postal ballot.

The Bill was being put through the In the end, the demise of Lords by the Conservative peer and the Bill came down to time thriller writer Michael Dobbs. His ‘My Lords, another hour, another frustration with the orchestrated group of amendments. We have 15 go‑slow tactics deployed by opponents groups of amendments to get through had become increasingly evident as today if we are to reach the end of the committee stage inched along: Committee stage.’

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Conservative Peer Michael Dobbs He said the failure to consult the British In the end it came down to time. people about the UK’s relationship When Lord Lipsey rose to move the with the EU was a failure by the entire closure of the day’s committee-stage political class, which he said had ‘flipped debate, the government chief whip and flopped like a hooked fish dragged Lady Anelay retorted that if this debate out on to the riverbank’. Lord Lipsey was ended she would not allocate any intervened: ‘Many of us are not against further days for debate. ‘The house a referendum; I myself am strongly itself will have collectively indicated in favour of one. We are against this that it no longer wishes to consider dog’s dinner of a Bill, which requires the committee stage. If the house improvement by every side of this house.’ disagrees the Motion, I will take that as a desirable, clear indication that we Lord Dobbs’ retort had a note of should complete the remainder of the weariness: ‘The noble Lord has made committee stage today.’ his point, again. I think that it is a point that he made last week in committee, In effect, she said, Lord Lipsey’s motion and I suspect that we may hear more would lead to a vote on whether or not of it again today … but there comes a peers wanted to kill the Bill altogether. point when all these nostrums about And by 180 votes to 130, peers voted parliamentary sovereignty require a to close the committee stage. The Bill dose of carbolic and common sense, was run aground. It was the final scene when we need to find a democratic of this particular drama – but the Bill balance.’ He added that it would be has been revived in the 2014–2015 most unwise of parliament to ignore session of parliament. So there will be the demands of the people. a sequel.

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HS2 – a band of rebels in the Commons

Europe was not the only divisive were all we would ever need for long- issue of the year. With its £21 billion distance travel. Today, we ask far too price tag and its serious implications much of the line. If we were talking for constituencies and communities about roads, it would be as if traffic along the proposed route, the Bill to still had to go up Watling Street, as if implement HS2, the high speed rail link the M1 and M6 had never been built, between London and Birmingham, was and we tried to solve our transport always going to be controversial – but needs by just patching up old roads … the government and the leaderships Cities and towns in the North deserve of all three main parties thought its better. Scotland deserves better. Britain wider economic benefits justified what deserves better.’ He was supported by ministers believed was a long-overdue his Labour shadow Mary Creagh, who upgrade to Britain’s creaking and said HS2 could transform the economic overloaded rail infrastructure. geography of the UK, and help rebalance the economy by creating Unsurprisingly, the combined weight of new skilled jobs and apprenticeships. the three front benches won the day, with a crushing majority – although The Bill’s arch opponent was the former a vocal group of rebels took their Welsh secretary Cheryl Gillan, whose defiance into the division lobbies. The Chesham and Amersham constituency transport secretary Patrick McLoughlin lies across the proposed route. She had opened the debate by reminding MPs put down an amendment to throw of the 1833 Bill to create what is now out the Bill, and criticised what she the West Coast Mainline: ‘It is worth called ‘the cosy consensus’ over it. A recalling that in 1832 parliament Labour opponent of the scheme, Barry HS2 has a £21 billion rejected the initial Bill because some Sheerman, insisted the critics were not price tag and has people objected, arguing that canals ‘flat-earthists’: ‘We know that our rail serious implications for constituencies and communities along the proposed route

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nobody would now suggest it should be abandoned or greened over’.

Another line of attack came from the Commons’ only Green MP, Caroline Lucas, who warned of destroying ‘irreplaceable’ ancient woodlands along the route.

Containing the eventual rebellion to 35 Conservative MPs (some voting for the Gillan amendment, some voting against the second reading David Cameron with the of the Bill) was a significant success HS2 declaration for the government whips. Labour’s infrastructure must be renewed and that well‑telegraphed support meant the there are real problems with capacity Bill was never in any danger of defeat, and much else, but this proposal is but that, paradoxically, made rebellion deeply flawed.’ a free hit for any Conservatives under constituency pressure. The The Labour former foreign secretary invisible factor was the number of Jack Straw, who represents Blackburn Conservatives who voted with teeth in Lancashire, said most of his gritted, but who still have serious colleagues representing constituencies doubts. Were Labour to change its in the North backed HS2. And he line at some later stage – and the Bill suggested that the creation of the M40 will not have been passed by the 2015 was far more disruptive for people general election – the votes needed to living in the Chilterns, adding: ‘but defeat HS2 might be there.

The Commons rejects armed intervention in the civil war in Syria

In what may well prove to be the single 2014–2015 parliament, MPs delivered MPs voted against a motion giving tentative most significant Commons vote of the a shocking rebuff to the coalition approval for British forces government, and rejected a motion to join an international seen as giving tentative approval for response to events in Syria British forces to join an international response to chemical weapons attacks in the civil war in Syria.

The result of that division caught even most MPs by surprise – a huge roar went up as they spotted which set of tellers (the members who count votes) were standing on the Speaker’s left – signifying that the ‘No’ side had won by 285 votes to 272.

David Cameron was immediately challenged by the Labour leader Ed

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Miliband, to confirm that he would Labour, but in the end faced a Labour not bypass the will of the Commons amendment calling for more evidence by using his powers as Prime Minister that the Syrian regime was responsible to commit UK forces without a further for the gas attack, and for what Ed vote. Mr Cameron told him, flatly, Miliband called a ‘legitimate road ‘I can give that assurance … It is very map’ to a decision to be set out. Mr clear tonight that, while the house Miliband stressed: ‘I am not with those has not passed a motion, the British who rule out action.’ And he rejected parliament, reflecting the views of the accusations that he was playing the British people, does not want to see issue for party advantage. British military action. I get that, and the government will act accordingly.’ When the debate moved to backbench MPs, Jack Straw, who was the The vote had been forced by a foreign secretary when Tony Blair’s backbench debate in the Commons on government took Britain into Iraq, 11 July, which ended with a 114 to 1 said the public was now much more vote approving a resolution requiring sceptical. And he warned that the UK that ‘no lethal support should be would inevitably be taking sides in the provided to anti-government forces in Syrian conflict. Syria without the explicit prior consent of parliament’. Other backbenchers reflected the doubts and fears that surrounded the So, when evidence emerged that sarin prospect of another intervention in the gas was being used by the Assad Middle East; the Conservative former regime against the rebels in Syria, defence secretary Liam Fox said that David Cameron recalled parliament. doing nothing would be appeasement. In the eight hours of debate that A Labour shadow minister, Jim followed, it was obvious that the bitter Fitzpatrick, had resigned rather than arguments over Iraq a decade ago support even the cautious amendment still reverberated, with talk of brutal put down by his leader. The former dictators and humanitarian disasters. Lib Dem leader Sir Menzies Campbell wondered what the West would do Mr Cameron recalled sitting in about atrocities committed using the chamber in 2003 as a young conventional weapons. The Green MP backbencher, listening to Tony Blair Caroline Lucas warned that intervention argue for Britain to take part in the without a UN resolution would be a invasion of Iraq – he was keen to draw return to the law of the jungle. Backbenchers reflected a distinction. There was no doubt, the doubts and fears that surrounded the prospect he said, that the Assad regime had of another intervention in committed at terrible atrocity, and the Middle East his voice cracked as he described the chemical attack near Damascus on 21 August: ‘The video footage illustrates some of the most sickening human suffering imaginable. Expert video analysis can find no way that this wide array of footage could have been fabricated, particularly the behaviour of small children in those shocking videos.’

The government had worked hard to draw up a motion acceptable to

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Senior Tory Sir Edward Leigh said MPs were speaking for a public that did not want war Respect’s George Galloway said the The senior Tory Sir Edward Leigh said attack could have been the work of MPs were speaking for a public that the Syrian rebels – and there was did not want war: ‘They are scarred public unease over the prospect of by what went on in Iraq. We were lied supporting them. ‘Take a look at the to in parliament and we are not going video of one of the commanders of to go down that route again. I voted the Syrian revolution cutting open the against the Iraq war and I will vote chest of a human being and eating against this one.’ his heart and liver. … Take a look at the videos of Christian priests having The Deputy Prime Minister Nick Clegg their heads sawn off – not chopped wound up the debate, insisting the off; sawn off with breadknives… government motion was not an amber Every religious minority in Syria – light for a military strike: ‘Iraq casts a there are 23 of them – is petrified long shadow, but it would be a double at the thought of a victory for the tragedy if the memory of that war now Syrian rebels.’ caused us to retreat from the laws and conventions that govern our world, The war in Syria continues, along with a massive many of which the United Kingdom humanitarian catastrophe helped to author.’

But, a few moments later, MPs voted down Labour’s amendment, and then, much more narrowly, the government’s own motion. In the USA the unwillingness of their main military ally to join the intervention produced startled headlines: ‘The British Aren’t Coming!’ noted one newspaper. The Commons’ verdict undoubtedly contributed to a US decision not to launch any military action. The war in

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The war in Syria continues, along with a to search back for centuries to find even massive humanitarian catastrophe. The a vague precedent) but the verdict of vote was undoubtedly historic (you have history has yet to be delivered.

Lord Pannick challenges the government over powers to deprive people of UK citizenship

The crossbench peer Lord Pannick simply striking down the clause, he would be a fair nomination for the called for a committee of MPs and single most influential member of the peers to study its implications. The House of Lords outside the party front new powers were aimed at people benches, which matters in a house who posed a serious national security where there is no overall majority. risk. But Lord Pannick questioned how He has been a thorn in the side of the powers would help. One objective successive governments. When he rises was to prevent suspects travelling to to speak, the government whips wince, terrorist training camps on a British because he has proved his ability to passport – but, he noted, the home mobilise the crossbenchers, who are secretary could already withdraw now the swing vote in the Lords. passports for that very reason, without making the passport holder Typically, he intervenes on issues of stateless. There were already too many human rights and due process – the dictators willing to use statelessness kind of issues that attract the small as a weapon against opponents, he legion of retired judges and senior added, and Britain should not give such lawyers in the upper house. This conduct respectability. amendment to the Immigration Bill proved a classic example of his ability to For the government, the home office extract concessions out of ministers. At minister Lord Taylor of Holbeach warned It was noted that the issue were proposals to give the home that a few people became British Home Secretary already secretary powers to remove British citizens and then sought to threaten had the power to prevent citizenship obtained by naturalisation, suspects travelling to terrorist training camps on ‘for reasons of the public good’, even if a British passport that left someone stateless.

Lord Pannick’s speech could be used as a template for any effort to persuade the House of Lords. He began by name-checking his Lib Dem and Labour supporters. Then he complained that ministers had added in the proposed powers at the last moment, just 24 hours before the Commons report stage debate, making the telling point that they had not, therefore, been properly considered by MPs.

Then he presented a carefully calibrated response – rather than

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the UK’s security, and even fought they have over a Bill. On 12 May, Lord against UK armed forces. ‘It would be Taylor announced a watering down perverse,’ he added, ‘if such people, of the proposals such that citizenship while attacking our forces or terrorising could be removed only when someone civilians, could invoke our protection.’ already held another nationality or could reasonably be expected to acquire The government lost the vote on Lord one. Lord Pannick hailed this as ‘a Pannick’s amendment by 62 votes – very substantial concession’. He did with crossbench peers breaking 53 to not continue to press his amendment, 6 in his favour, and with an unusually although Labour peers did force a further large rebellion in the normally highly vote. It was a typical example of the disciplined ranks of Lib Dem peers. way the Lords have, with increasing The result was that ministers offered effectiveness, made detailed changes to a compromise proposal, which was new laws, and forced the government debated during the ‘parliamentary to, at least, meet them half way. But the Crossbench Peer Lord Pannick ping-pong’ on the Bill, when the Lords issue of deprivation of citizenship may and Commons settle any differences now re-emerge because of events in Iraq

‘Dare to be a Daniel’ – the Commons says farewell to Tony Benn

With a couple of breaks, Tony Benn spent almost 50 years in the Commons. He had to fight a long battle to remain an MP when his father died and he inherited his peerage. He sat in the cabinets of Harold Wilson and James Callaghan, and came within an ace of winning control of the Labour Party at the head of a left-wing insurgency.

The tributes were opened by the Deputy Prime Minister Nick Clegg, who noted: ‘Over his lifetime, Tony Benn went from being vilified to being lauded by the press; perhaps there is hope for all of us. [That brought a shout of derision.] Okay; perhaps not. He had mixed feelings about Tony Benn (3 April 1925 this. He once said: “If I’m a national to 14 March 2014) treasure in The Telegraph, something’s gone wrong.”’ Almost the final words in Tony Benn’s farewell address to the House of Sir Peter Tapsell, the longest-serving Commons, where he had sat for half a MP, recalled Mr Benn’s oratory: ‘At century, were: ‘I love the place.’ When his best, he was spellbinding, so that he died, at the age of 88, the house listening to him one was sometimes returned the compliment, with an in danger of being intellectually swept afternoon of tributes. towards some of the wilder shores of

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politics. Harold Wilson – they were chalk and cheese – famously said of him that he was the only man he had ever known who immatured as he grew older, but that was his great charm.’

Labour’s deputy leader Harriet Harman was one of dozens of MPs with personal recollections. She described how, one evening, as a new MP with young children, she was sitting, exhausted, in a Commons café waiting for a late-night vote: ‘Tony came and sat down next to me, and said, Sir Peter Tapsell, the “You look exhausted. You should be longest-serving MP at home.” I said that I could not go home, because I had not been let off The key to his father’s beliefs lay in his by the whips. He said: “I can give you upbringing: ‘He was, at heart, not just a really important piece of advice for a socialist; he was a non-conformist your future. You do not have to worry dissenter. His mother taught him to about the whips; I never do.”’ believe in the prophets rather than the kings, and his father would recite these Hilary Benn, Tony’s son, sat listening to words from the Salvation Army hymn, the tributes. Five Benns have sat in the which I think best explain what he Commons across three centuries and sought to do in parliament: four generations, with the prospect “Dare to be a Daniel of more to come. He said his father Dare to stand alone had won 16 elections: ‘Fifteen of Dare to have a purpose firm those elections enabled him to walk Dare to make it known.” through those doors and take his place in this chamber. One of them – the … Whatever the scribes and the by-election he fought after the death Pharisees may have to say about his of his father – did not. He was barred life, it is from the words and kindnesses from entry to the chamber on the of those whose lives he touched that instructions of the Speaker because, we – those who loved him most – take it was alleged, his blood was blue. the greatest strength. After all, any life His blood was never blue; it was the that inspires and encourages so many deepest red throughout his life.’ others is a life that was well lived.’

The coalition splits over knife crime

It was always likely to happen as the offence of possession of a knife in coalition entered its final year; sooner England and Wales. The Conservative or later one of the two coalition backbencher Nick de Bois had parties was going to gang up with consistently campaigned for tougher the opposition to defeat the other measures against knife crime; as in partner on some electorally-potent many areas of London, knife crime was issue. As it turned out, the issue was a serious problem in his Enfield North mandatory sentencing for the second constituency, and he put down two

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‘little more than an occupational hazard’. His amendment would ensure that people aged over 18 caught carrying a knife for a second time would automatically get a six-month jail sentence – those aged over 16 would get a detention and training order of at least four months. The courts, he said, should send a clear message – particularly to the two and a half thousand 10–17-year-olds caught with a knife in the previous year.

The Conservative Tim Loughton, a former children’s minister, said gang culture was reaching primary schools, The amendment would and younger children were copying ensure that people aged older gang members whom they saw over 18 caught carrying carrying knives. Mr de Bois agreed – the a knife for a second time amendments at the report stage of the ‘journey to destruction’, as he called it, would automatically get a Serious Crime and Courts Bill, which six-month jail sentence involved picking up and carrying a knife would impose the compulsory sentences for the first time. for both adults and minors. Labour’s justice spokesman Andy This went beyond agreed coalition policy, Slaughter said that in his home but intensive campaigning by Mr de Bois borough of Hammersmith and Fulham had rallied support among Conservative there had been more than 800 knife backbenchers – and, as the vote crimes since 2010 – and in the previous approached, the party leadership decided year more than half the murders in to allow them a free vote and instructed London had been committed with a Conservative ministers to abstain. Labour knife. He supported Mr de Bois – but also backed the proposal – and so when a key reason for his support was that they joined forces with the Conservatives judges would be able to use discretion the Lib Dem side of the coalition found in exceptional cases. And he noted itself outvoted. that, in 2011, the Liberal Democrats had supported mandatory sentencing In the debate, Mr de Bois said the Conservative Tim for people who used a knife in a Loughton, a former current sentences for possession were Children’s Minister, said threatening way. He could not see any gang culture was reaching distinction of principle between that primary schools measure and this one.

The Liberal Democrat Julian Huppert retorted there was a simple distinction: brandishing a knife at people was a far more serious matter than carrying a knife. In the first case, a direct threat was being made; in the second, the knife might be for personal protection – and he mocked Labour for supporting mandatory sentences, so long as there was discretion.

A note of caution came from the Conservative Sir Edward Garnier, a

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former solicitor general, who said younger teenagers who would not be MPs should consider why judges did caught by Mr de Bois’ amendments. not always give a prison sentence for But when it came to the vote MPs voted possession of a knife, adding some 404 to 53 in favour of introducing of the most difficult cases involved mandatory sentences.

A hero’s welcome – David Cameron reports back to the Commons

For a leader outvoted 26 to 2 by his The Prime Minister’s objections to fellow EU leaders, David Cameron Mr Juncker – whom he criticised as received a near-ecstatic welcome an old-guard EU federalist – had been from his troops when he arrived to overridden, but his party united around deliver a statement to a noisy House of him. The Labour leader Ed Miliband Commons on the decisions reached by and a parade of Labour ex-ministers the Ypres Council of Ministers. accused Mr Cameron of grandstanding ‘I always knew he had lead in his and alienating allies, who might pencil,’ said Eurosceptic backbencher have helped block the appointment. Stewart Jackson. Pro-EU Tory Richard It was, Mr Miliband said, a gloomy Ottaway said Mr Cameron had stood precedent for the Prime Minister’s up for British interests. Former cabinet planned renegotiation of Britain’s EU minister Peter Lilley compared him membership, which was to precede his to Mrs Thatcher. Backbencher James promised referendum: ‘His renegotiation Duddridge noted his stand had gone strategy is in tatters. We know where The Prime Minister’s down very well in Southend. it would end, he would be caught in objections to Mr Juncker were overridden by his fellow EU leaders, but his party united around him

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of the pan-EU European People’s Party, where he might have been able to block Mr Juncker’s candidacy before it had even started. He could have had ‘influence in private rather than impotence in public’, Mr Kennedy said.

Meanwhile, some on Mr Cameron’s own side put down markers for that renegotiation. Sir Peter Tapsell criticised the free movement of labour across

Mr Cameron said it was a the EU. Christopher Chope called for point of principle for him ‘revision, if not abolition’ of the Working that the EU presidency Time Directive. Jacob Rees-Mogg called should be determined by the gulf between his backbenchers for Britain not to opt into the European national leaders who want to leave and what he Arrest Warrant, and Robert Halfon called can negotiate … The Prime Minister for a cut in the EU budget. has failed over Mr Juncker; he was outwitted, outmanoeuvred, out‑voted.’ Some backbench Tory voices hinted at problems to come. Douglas Carswell Mr Cameron retorted that previous asked simply: ‘What would have British leaders would have been to happen for my Rt Hon Friend to able simply to veto an unacceptable come back from his negotiation and candidate for the presidency. But recommend that people vote “Out”?’ Labour governments had given that Mark Reckless recalled the Labour Prime right away. And it was a point of Minister Harold Wilson’s promise to principle for him that the presidency win ‘big and significant improvements should be determined by national on the previous terms’ in his 1975 leaders, not by the voting in the renegotiation of British membership, with European Parliament elections – that the implication that what was actually was an erosion of national sovereignty. delivered was only cosmetic. Mr Cameron replied that he was confident he could A series of MPs – notably pro-EU deliver the changes he sought. Conservative Sir Nicholas Soames – suggested there was a potential These exchanges were just another pro-reform alliance within the EU, episode in the continuing debate over and urged the Prime Minister to seek Britain’s place in – or out of – the EU, a like‑minded allies. The Liberal Democrat debate which has become increasingly Charles Kennedy rebuked Mr Cameron important with the rise of UKIP, and for taking the Conservative MEPs out the approach of the general election.

The Lords debate assisted dying

After a marathon ten-hour debate that doctors, judges and a severely disabled saw speeches from 130 peers, the House peer. Personal experiences were related of Lords gave a second reading to a and the theological, philosophical and carefully-limited Bill intended to allow practical implications were discussed. terminally ill people choice over how they die. It was an impressive, intense debate, The Bill was presented by Lord Falconer, with speakers including an archbishop, who served as lord chancellor under an ex-archbishop, senior lawyers, Tony Blair. He proposed that doctors

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should be permitted to prescribe lethal medications to patients judged to have less than six months to live. The present law forced many people facing a painful death to hoard drugs or put a plastic bag over their head, and they died alone to avoid implicating family or carers in their suicide. His Bill would not mean more death, but less suffering.

He was opposed by another former lord chancellor, Lord Mackay of Clashfern, who asked if it could be compassionate to confront a dying person with such Lord Falconer proposed a decision; but he did not want the that doctors should be Bill to be rejected at this stage, to permitted to prescribe On the other side of the argument, lethal medications to allow further debate on the issue. Lord Carey, the former Archbishop patients judged to have Also opposed was the Most Rev John less than six months of Canterbury, said he now believed Sentamu, the Archbishop of York, who to live assisted dying was ‘quite compatible’ rejected the idea that assisted dying with being a Christian, and the was ‘an assertion of human freedom’. Conservative Baroness Wheatcroft Baroness Greengross, a former director described her mother’s last agonised general of Age Concern, focused on the hours. She would have seized the need to help people who have become option to die, she said. incapacitated and are physically unable The Bill was given its second reading to end their lives without help. They without a vote, with even its should have the same rights as the opponents arguing that a chance to able‑bodied, she said. examine the issues it raised in detail, One of the most moving speeches in committee-stage debate, would be came from Baroness Campbell of valuable. But, even if it is ultimately Surbiton, who has spinal muscular approved by the Lords, the Bill looks atrophy. Speaking from her wheelchair, unlikely to be given debating time in she said the Bill was about her, and the Commons, and so stands little people like her. ‘It frightens me chance of becoming law. But it will add because in periods of greatest difficulty to pressure for the next government to I might be tempted to use it,’ she said. act, after the 2015 election. Baroness Campbell of A similar view came from the Surbiton Conservative former cabinet minister Lord Tebbit, who spoke of his wife, who was injured in the 1984 IRA bombing in Brighton. Carers were all too familiar with the moments of ‘black despair’ in which those they cared for would wish they were dead so their loved ones could get on with their lives, he said. And he warned that there would be plenty of human and corporate ‘vultures’ with an interest in pushing people into assisted death.

64 | REVIEW OF PARLIAMENT Acknowledgements

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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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