Kerr Report: Framework for service change in
the NHS in Scotland
The UNISON Scotland Response October 2005
Executive Summary
UNISON Scotland welcomes the opportunity to comment
on the Kerr report. UNISON is Scotland's largest trade union
representing 150,000 members delivering public services. We
represent the majority of the employees in the National Health
Service in Scotland representing senior managers, nursing staff
at all levels, Allied Health Professionals, administrative and
clerical, ancillary staff, laboratory staff, technicians and
paramedics. We broadly welcome Professor Kerr's report on the
future of the NHS in Scotland.
UNISON agrees that the workforce is the key to
NHS capacity and service re-design. It is NHS staff who will
deliver the NHS of the future and therefore their representatives
must have a strategic role in the implementation of any changes.
Representatives should be involved at all levels during the
development of the implementation plan rather than asked to
comment on a finished plan. Staff are in a unique position to
contribute to the plan as they view the health service from
within as providers and as patients or carers. Partnership working
with staff representatives needs to be embedded in structures
at all levels (within the Scottish Executive Health Department
through the Scottish Partnership Forum, at Regional Planning
Committees, in Area Partnership Forums and Community Health
Partnerships).
The NHS in Scotland has a highly trained and committed
staff. There is a need to build on the well of human resource
through a culture of improved leadership, collectivism, and
engagement with all staff. Re-profiling the workforce requires
substantial and sustained investment in education and training
and is the key to unlocking capacity and to modernising models
of NHS care.
UNISON is opposed to the NHSiS pursuing "partnership
with independent sector providers as required" . The use
of the private sector in this way will drain valuable resources
from the NHS. These companies can only provide services by taking
staff away from the NHS. This makes it harder for the NHS to
perform, recruitment is costly and time consuming and all new
staff take time to operate at their top level. The NHS has also
paid to train and develop the skills of theses staff. The NHS
is not able to recoup this investment if staff leave. The use
of private providers also undermines the viability of the services
within the NHS; there is less money available to the NHS to
provide services; Staff will find it harder to develop skills
if they do not get the opportunity to practice procedures regularly.
UNISON is opposed to the allocation of funding
to Boards being based on performance and incentivising the allocation
of resources. This is not the best way to provide for increased
equitable high standards of delivery.
UNISON also opposes the use of performance
related pay for senior staff within the NHSiS. Managers do not
achieve targets by their own efforts alone. Success reflects
the output of all those who work hard to deliver services. Rewarding
only those at the top undermines the spirit of co-operation
necessary to deliver services and drive forward change in the
NHSiS.
Introduction
UNISON Scotland welcomes the opportunity to comment
on the Kerr report. UNISON is Scotland's largest trade union
representing 150,000 members delivering public services. We
represent the majority of the employees in the National Health
Service in Scotland representing senior managers, nursing staff
at all levels, Allied Health Professionals, administrative and
clerical, ancillary staff, laboratory staff, technicians and
paramedics. We broadly welcome the reflections of Professor
Kerr on the future of the NHS in Scotland. UNISON is keen to
ensure that UNISON members' experience as health care providers
informs the process of change and so ensure that the NHS in
Scotland is one "fit for the future".
Implementation
UNISON believes that the policy of ‘Partnership'
developed by Scottish Executive Health Department, the Service
and Staff Side since 1997 is the key to successful implementation
of the Kerr Report. This policy has a track record of success
which can continue to help transform NHS Scotland over the next
twenty years.
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A new SPF can provide a first class policy
sounding board for Ministers, with key representatives
from SEHD Delivery Managers, key players from the Service
and Staff Side collaborating to achieve the best possible
standards of patient care.
WORKFORCE ISSUES
"The NHS of the future will require a set of staff
providing a different service, in different working environments
and with different skills and roles".
This cannot be achieved by top-down dictate. It
requires co-operation and collaboration between employers and
staff, between staff and between employers and staff representatives.
It requires a clearly agreed direction of travel. It requires
employers and staff side organisations to act as pilot and co-pilot.
"It will be essential to link service planning
to workforce planning at every level (local, regional, national).
We need to be sure that we make the best and the most appropriate
use of our staff".
Again partnership working will be the key to unlocking
the capacity and potential.
Information and Communications Technology
UNISON acknowledges the need for an electronic
patient, record and quantum leaps in ICT provision for case
management and care co-ordination. There is partnership engagement
around the E-health agenda. However, UNISON maintains that NHS
Scotland is too embroiled in 'partnership' with private sector
companies around key ICT Infrastructure Project.
We do not believe that this will lead to long-term
effectiveness on value-for-money. Internal capacity and capability
on ICT needs to be re-introduced and developed within NHS Scotland
to be strategically and operationally effective in the long
run.
AFFORDABILITY AND SUSTAINABILITY
UNISON recognises the high levels of current investment
in NHS Scotland. There are however areas where value for money
should be examined, in particular:
LOCAL SERVICES
UNISON supports the concept of local care which
is safe, effective and sustainable. We accept the premise that
the management of long-term conditions must succeed at local
level, otherwise demand on acute services will continue to increase
and will never be met. There is a need to invest in primary
care and to co-ordinate the management of long-term conditions:-
Multi-disciplinary Teams
There is already considerable experience and good
practice here. However, there is a need for investment in staff
resources and training and to manage 'single system' resources
between acute/primary services in for example, occupational
therapy and physiotherapy working in wards and in the community.
Integration Health & Social Care
There needs to be clear role definition, managerial
and professional accountabilities. Pay and conditions of service
packages need to be fair. Pay needs to be reflective of equal
pay and the levels of skill and competence and freedom of practitioners
to act on behalf of patients/clients.
Continuing Care of the Elderly
UNISON does not believe all hospital admission
can be avoided and that the care required by vulnerable elderly
is not always acute assessment and rehabilitation in District
General Hospital setting. There is a requirement to plan and
deliver an optimum number of continuing care NHS beds for the
elderly for the provision of intermediate and end-of-life care,
with appropriate medical, nursing and AHP input. NHS Scotland
is a "cradle to grave service". Increasingly with demographic
changes there is a need to focus on frail elderly with chronic
disease(s) in terms of resource allocation.
Given the current growth in the elderly population
in Scotland there is a pressing need to make geriatric nursing
a rewarding and attractive career option for nursing staff.
Care co-ordination/Case Management
The ICT and systems do not exist in a systematic
way across all client groups between Health Boards and Local
Authorities across Scotland. ICT systems within and between
NHS employers do not inter-face, nor do NHS systems with those
of the 32 local authorities. The resourcing and development
of universal integrated systems should be a priority. There
should be a common mandatory GP ICT system based on the proprietary
GPAS system.
Community Hub Resource
Collaboration through CHPs for the development
of "Community Hospitals" seems an excellent proposal, particularly
in relation to care of the elderly. Local resource hubs in a
rural or urban setting with access to diagnostics tests and
investigations; minor injury unit, perhaps allied to day care
provision on a 'campus' basis with Social Work seem a crucial
future networked resource to the management of the care of the
growing elderly population. Such a network of resources will
help stem the trickle of people with locally manageable conditions
into becoming a flood into beds within District General Hospitals.
KERR RECOMMENDATIONS
UNISON supports the four recommendations at Kerr
page 28 and four associated actions. These latter four projects
in our view are most likely to succeed if progressed through
partnership working.
URGENT LOCAL CARE
UNISON sees considerable merit in Kerr's classification
of levels of Unscheduled Care and associated models of care
at each level.
Levels 1 and 2 require again clear role definition,
training and development in extended practice.
UNISON strongly supports initiatives to improve
the valuable role performed by NHS 24 as part of the unscheduled
care system and the move to a more localised support .The concept
of 'Community Casualty Unit" is a good one and requires an approach
that is safe and sustainable.
UNISON supports the proposal that the configuration
of emergency receiving and admission at level 3 should be planned
regionally.
Level 4 provision requires Scotland-wide planning
and delivery.
Transport considerations are a priority consideration
for patients and relatives alike.
UNISON supports the 4 recommendations on page
33 and three consequent actions.
We welcome the focus on rural communities. We
have already alluded to the need to focus debate in Scottish
Ambulance Service around resourcing, training and development.
TOLERATION OF RISK
UNISON supports the proposal on page 37 to create
a strategic task force to examine the issue of specialisation
and the impact on clinical outcomes. Any planning and delivery
of models of care should be based on rigorous risk assessment
and patient safety is clearly the prime factor.
EXTENDED WORKING DAY/HOSPITAL AT NIGHT
The recommendation to provide care on the basis
of an extended working day, with overnight care for medically
stable patients is fundamental to the management and rostering
of all hospital services. Its impact and pay and allowances
issues which flow from it need to be carefully considered. Such
developments would need to be and seen in the context of Agenda
for Change, junior doctors hours, modernising medical careers.
There needs to be significant partnership input around these
issues.
We do not wish to create an 'out of hours' difficulty
within our in-patient facilities in hospitals.
Partnership
Recommendation 1(a)-(b) (p39) should be informed
by partnership input at Scottish and Board levels.
The planning and delivery functions of SEHD should
work closely and collaboratively with the revised and re-focused
Scottish Partnership Forum.
RURAL COMMUNITIES
Extended roles for members of the rural healthcare
team, building on current best practice, will require sustained
investment in staff training and development.
UNISON supports the development of community hospitals.
We maintain, however, that there is a need to plan and maintain
an optimum provision of long-stay care of the elderly in-patient
beds. Such community hospitals have to be a resource centre
base for in-patient and community based services. They can also
act as the base for out-of-hours multi-disciplinary teams. Transport
considerations must be a key planning factor in association
with other agencies within NHS (NHS 24, SAS etc.) and externally.
UNISON strongly welcomes Kerr's recommendation
on the development of Rural General Hospitals (RGHs) for Highland,
Grampian, Borders, Dumfries, and other rural catchments areas.
UNISON supports recommendations 1-4 (p43).
QUICKER TREATMENT
UNISON supports the concept of 'streaming' elective
care away from emergency care. However, the 'emergency' skills
of clinical and other staff (nursing and theatre staffs) concentrating
on consolidated elective specialities require to be maintained.
UNISON supports the staff of diagnostic capacity
in the primary care sector. This requires to be resourced in
terms of equipment and staff.
UNISON supports shared referral management systems
but the systems technology skills and protocols need to be in
place.
UNISON supports Recommendation 1 (page 46/7) with
the proviso that there needs to be proper back up for emergency
intervention on-site or from DGH sites.
UNISON supports Recommendation 2, with full partnership
discussion of the implications for working hours, practices
and an examination of any consequences for pay and conditions.
We support Recommendations 3 and 4.
UNISON is opposed to Recommendation 5: WE believe
we should maximise the use of NHS Resources (including the Golden
Jubilee Hospital, Clydebank) through greater efficiency and
choice of appointments. Improved referral systems, streaming
of patients, and maximisation of use of equipment and resources
should negate the need for reliance on the independent sector
for acute services (Diagnostics and surgical services).
Nor do we think that the independent sector is
able to deliver primary intermediate and end -of-life care services
to older people which is a prime NHS function.
The private sector can only perform by ‘poaching'
valuable staff resources developed by NHS Scotland.
We support Recommendation 6.
HEALTH INEQUALITIES
Health inequalities across the population of Scotland
remain significant. Contextual issues of poverty, housing, employment,
transportation are obviously of great significance
UNISON supports Recommendations 1: 3 (page 48).
We need particularly on recommendation 2 to invest in District;
Community Nurse and Health Visiting resources to enhance front-line
services in the community.
NHS SPEND
The Regional Planning Groups, which are given
a new emphasis in Kerr's recommendations, should be developed
as 'partnership' groups and work in accordance with partnership
principles in relation to service and workforce planning.
Similarly CHPs need to have effective partnership
arrangements to best deliver their key objectives. UNISON would
caution CHPs taking on financial delegation from NHS Boards.
The impact of CHPs becoming fully responsible for financing
all services from delegates' budget fundamentally alters the
funding and financial accountability arrangements in NHS Scotland.
UNISON would oppose the use of financial incentives
to 'reward' performance of NHS System. The experience of competitive
'trusts' and the NHS in England & Wales shows that this
is not the best way to drive up overall equality and standards
of care.
UNISON would oppose performance related bonuses
for Clinical and Managerial staff. The provision of NHS services
is a team effort delivered collectively.
Planning mechanisms at Recommendation 1 should
be partnership bodies. UNISON supports Recommendations 2-4(page
52). In Recommendation 5, CHPs should develop effective partnership
arrangements. UNISON would oppose Recommendation 6 as counter-productive
to enhancing overall performance and quality in NHS Scotland.
PUBLIC AND PATIENT VOICE
UNISON supports the KERR recommended actions on
p54/55. Our 58,000 members in Scotland and their families are
users of NHS services and deserve a voice as 'consumer' interests.
UNISON believes that directly elected Health Boards would strengthen
the public and patient voice. We therefore support the Direct
Elections to NHS Boards (Scotland) Bill being promoted by Bill
Butler MSP.
INTEGRATION
UNISON recognises that CHPs present a fresh opportunity
for inter-agency co-operation. We repeat that delivery of key
CHP objectives can be best achieved through building the CHP
structure on the foundations of the 'partnership' principles
and policy central to the way of working in NHS Scotland. UNISON
supports the Recommendations at 1 and 2 (page 57).
UNISON supports the development of a common ICT
system compatible with other agencies. Such an ambitious project
is best advanced in the same 'partnership' manner as other strategic
developments around Shared Services, Logistics and Procurement.
The project requires to be underpinned by the Organisational
Change Policy.
UNISON supports Recommendations 1-3(page 59).
The target in Recommendation 2 is ambitious.
STAFF
Partnership Working is the key to empowering front-line
staff. National Strategies for service change should be informed
by debate in the renewed and refocused Scottish Partnership
Forum and delivery will be assisted by the reform of SEHD structures.
Strong and effective leadership is required.
Develop its staff and NHS Scotland will develop
its services and enhance quality. The wealth of knowledge, skills
and experience of all NHS staff should contribute to change
and innovation. Best practice needs to be systematic.
UNISON welcomes the suggestion of an in-house
capacity to develop change, rather than reliance on expensive
external consultants.
Collaboration with the academic community and
other countries should inform strategic thinking on service
re-design and development.
UNISON supports Recommendation 1-3 (page 61)
STANDARDS AND QUALITY
UNISON supports Recommendations 1-4 (page 62).
Standards can only be raised by improvements, not only in clinical
governance, but also Staff Governance considerations.
CONCLUSION
The challenge of change can only in our view be
achieved through mature partnership working with staff side
organisations in NHS Scotland at all levels.
If ICT is the 'glue' to integration of NHS care
co-ordination then partnership working is the strong enabling
force which will drive and support:-
This can be achieved within an employee relations
environment which is stable, positive, constructive and forward-looking.
For Further Information Please Contact:
Matt Smith, Scottish Secretary
UNISON Scotland
UNISON House
14, West Campbell Street,
Glasgow
G2 6RX
Tel: 0870 7777006
Fax: 0141 342 2835
e-mail: matt.smith@unison.co.uk
Kerr
Report Response