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The People Manager

You need more than a change in the law to improve care

17 April, 2014 Posted by: -

When I was a specialist social worker working with older people who had dementia I was very concerned about the willingness of relatives, housing officers, ward staff, GPs and fellow social workers to ignore the wishes of people with dementia based on the fact that they were confused and forgetful.

What this meant was they were admitted to a residential or nurseling home without being involved in the decision. As a result, anyone visiting one of these homes would be accosted by a distressed resident asking to be let out as they wanted to go home. In response, the staff would lock the doors, keep the individual under sedation or use the food tray attached to an arm chair to in effect pin the person into the chair.

The person’s home having been given up or sold, staff would inform them “you live here now”. If this distressed them or they became aggressive in their attempts to leave then staff simply upped the medication.

Times have changed – in theory

Being old and suffering from dementia all too often meant the risks they posed to themselves overruled their human rights. The difference in these cases to other people with a mental health problem was the total lack of protection for the person who was to be deprived of their liberty till the end of their days.

A whole range of other decisions would be made about their hom , their possessions, how their personal finances were spent, when they had a bath and even if they had sugar in their tea.

It is over 30 years since I was a social worker, attitudes have changed, care staff have specialist training and the law has changed with the introduction of deprivation of liberty guidelines, which independently balance against risks.

‘Without adequate resources and changes in attitude the reality remains much the same’

Well that’s the theory, but a recent report by the Care Quality Commission concludes it is not the reality. All too often dementia in old age leads to relatives and professionals disregarding a person’s rights in ways no one would get away with towards younger people.

The report says hospitals and care homes often act to deprive an individual of their rights, either through ignorance or convenience, and that too many local authorities are under-resourced to carry out their duties of assessment and safeguarding.

This is yet another example for those who think the job is done when the law is changed, not appreciating that without adequate resources and changes in attitude the reality remains much the same.

The politics of language

14 April, 2014 Posted by: -

Do you know how to tell which type Irish pub you are in? Ask for a whiskey. I learnt this when I asked for a glass of Bushmills in an Irish pub in Birmingham. The relevance of which will be dealt with later.

I noted that in two articles in The Guardian last week on the topic of race and racism the expression “people of colour” was used as opposed to “black” or “ethnic minorities”. Has there been a shift in the correct terminology, and if so what’s the thinking behind it? To answer this question I did what most people do these days and googled it.

“Coloured people (which in South Africa means ‘people of racially mixed ancestry’) has in the United States a connotation different from people of coloUr… Coloured is often taken as a slur, even when not so intended, and so this term is better replaced by black. People of colour, on the other hand, is a phrase encompassing all nonwhites… When used by whites, people of colour usually carries a friendly and respectful connotation, but should not be used as a synonym for black; it refers to all racial groups that are not white,” wrote William Safire in The New York Times in 1988.

In US history, “person of color” has often been used to refer only to people of African heritage. Today, it usually covers any person of African, Hispanic, Native American, Asian or Pacific Island descent, and its intent is to be inclusive.

Cultural sensitivity

So the expression person of colour comes from the US. I don’t know why it has taken so long to a cross the Atlantic. People of colour simply identifies those who have in common the fact that they are not white. It includes people of mixed race, although President Obama is more often described as the first black president of the United States rather than mixed race.

‘People of colour is preferred to “non-white” or “ethnic minority” because these expressions are not as neutral as they may appear’

In the US for people of colour the experience of growing up even in the same neighbourhood is different depending on whether you parents were immigrants or descendants of slaves. This distinction doesn’t seem to apply in the UK, where there tends to be either a religious divide in the community, Muslim or non-Muslim, or simply a case of first generation immigrants versus second or third generation, (those more recently arrived versus those born in the UK).

People of colour is preferred to “non-white” or “ethnic minority” because these expressions are not as neutral as they may appear to those less aware and sensitive to the language of race. People of colour sounds more positive and is more inclusive. If you are referring to a specific ethnic group then the convention is to use people of African heritage or Asian heritage. I have noticed people in education use this terminology yet most of us use the terms black and Asian.

If this seems all rather politically correct to you then think how confusing it must be to people around the world who simply refer to “the Irish” with no awareness or sensitivity to issues of nationality, religion, history or culture. Bushmills is an Irish whiskey that in Birmingham used to only be served in the Republic of Ireland pubs.

I don’t want to be a consumer, I'm happy to be a patient

9 April, 2014 Posted by: -

A consumer-driven health system is better than being finance driven, but I think I would prefer practice-led even over patient-led. Maybe doctor doesn’t know what’s best for me when it comes to independence, choice and risk but I am happy to defer on medical issues.

‘I don’t want to be a consumer. I am happy to be a patient. All I ask is that my nurse, GP and consultant treat me like an adult capable of making decisions about my own life’

As for personalisation, it is well established in social care and has only a limited success: excellent for people with a disability who are articulate and assertive provided the budget is sufficiently generous to meet their needs in the way they desire; totally inappropriate for people with dementia and those offered a budget that is theirs to spend as they see fit but insufficient to meet basic needs.

Recurring nightmare

A nightmare because if you don’t trust your GP or consultant who do you trust?

A nightmare because you just don’t have the energy to research for the “best” provider and negotiate a package of care.

A nightmare because the prospect of employing carers and sacking them just makes you anxious.

A nightmare because trying to manage an inadequate budget just adds to your stress. And what happens if your needs change, the provider goes out of business, the eligibility criteria changes and your personal budget is reduced or withdrawn?

I don’t want to be a consumer. I am happy to be a patient. All I ask is that my nurse, GP and consultant treat me like an adult capable of making decisions about my own life.

A new boss to navigate us through the next few years

8 April, 2014 Posted by: -

The new NHS boss, Simon Stevens, on his first day said: “Successfully navigating the next few years is going to be a team effort, involving the biggest team in the biggest effort the NHS has ever seen.”  

‘Sometimes you have to ignore the sat nav when common sense tells you you’re going the wrong way’

When it comes to navigating your way around I just want him to bear in mind my recent experience. 

Driving around on holiday in Florida was made a lot easier by the sat nav we took with us, pre loaded with all our destinations,hotels, museums and restaurants. We thought it would be particularly helpful in finding our way out of Miami and through the series of spaghetti junction like motorway interchanges that surround the city.

Something wrong

After half an hour we started to doubt the confident voice directing us to “keep left”. We had left the city centre and found the motorway OK but we had yet to see a highway sign for our destination. We expected the journey to take about two hours. After an hour on the motorway we were convinced we were heading in the wrong direction and we were. It turns out that in a country as big as America there is more than one place with the same name. So it’s really important you get the right state. I should have realised that something was wrong when the estimated time of arrival was two days, not two hours!

We all have a similar sat nav story. Now here’s the thing, sat navs have replaced maps and our leaders no longer refer to the “road map” when describing where we are going and how we are going to get there. We rely on their confident voice to reassure us that we our still heading in the right direction. We know we need to trust what we are being told. Sometimes the route is not the one we expected, sometimes the quickest way is not the most direct and sometimes the directions are a little confusing but at this speed there is little time to think or question just follow.

But what happens when not every one agrees on the desired destination let alone the best way to get there? What happens when during the journey the destination is altered? What happens if delays on route force a rethink about whether another way may be quicker?

Sometimes you have to ignore the sat nav when common sense tells you you’re going the wrong way

In the NHS you need political skills to survive

1 April, 2014 Posted by: -

A study by consultancy Hoggett Bowers found the main reasons for chief executive departures included difficulties in personal relationships with their chair or a senior figure in a stakeholder organisation not successfully judging the “local politics”, and not recognising key power brokers.

Despite its importance, most middle and senior managers have never had any training or development in political skill.

‘The business case for closing a hospital or transferring a service may be very strong but it may also be very politically sensitive’

What is political sensitivity, political awareness or being political astute? It is being aware of and sensitive to the issues that will be important to important others even if they are not important to you. 

The business case for closing a hospital or transferring a service may be very strong but it may also be very politically sensitive. Recognising why and to whom is the first step. The next is taking this into account the way decisions are conveyed and the timing of announcements.

The clinicians may be on board and the trade unions reassured but the chair will also be concerned about the reaction of the local media and the local MPs will be sensitive to public option – keeping their seat may depend on how the issues is managed.

Need for sensitivity

The need for political sensitivity by managers has always been explicit in local government. In every person specification for a senior job in local government it will state the need for political sensitivity. This is usually taken to mean recognising that councillors are elected to represent local people and that local government services are accountable to local people via their local councillor.

Both officers and members (politicians) would claim to be motivated by the desire to make a difference. Both recognise that unpopular decisions have to be made to balance the budget but only members need to get re-elected. This difference explains why members have been known to vote for the strategy but speak out against its implementation.

Recent examples would be the closure of libraries. In other circumstances it is a case of accepting the business case but stating it is politically undeliverable. A few years ago this happened a lot in Labour run authorities, which wished to hold on to their elderly person’s homes. Another example would be the decision to build a waste incinerator as part of a strategy for removing the reliance on landfill sites but then joining a campaign against citing the incinerator in their ward.         

Politicians are very media sensitive, they seek the photo opportunity, they desire good press and they want local people to see what they are doing for them. However, good news doesn’t sell news papers.

The local press and radio also see themselves as champions of local causes for local people – often, it appears, in opposition to their elected representatives. They may be quick to present negative stories usually around well established stereotypes of bureaucracy and red tape, politically correctness gone mad and shocking waste of tax payers money.

This also helps explain why something a manager may consider trivial, a politician may consider very significant. A complex partnership agreement woven together over many months of skilful and patient negotiations can quickly unravel if the manager fails to appreciate the significance attached to the size and position of the council’s logo. To members frustrated that the public often doesn’t realise the council’s financial contribution to such partnerships the logo is a powerful symbol, not an afterthought.

The different perspectives that managers and members bring to a situation can be illustrated by their approach to the opportunities offered by a successful bid for money. A manager secures additional funding to transform and modernise a small number of libraries. Following a detailed study, a clear set of criteria is established to identify which libraries will benefit from this extra money. A politician wants to give a facelift to as many libraries as possible, especially in the wards controlled by their party, timed to coincide with local elections. A way foreward might be bringing forward the repairs maintenance programme for the libraries not benefiting from the successful bid.

Understanding the political agenda, having the strength to resist inappropriate requests, being astute enough not to be seen as obstructive and sufficiently creative to identify options are all part of the skills required to be a senior manager in health and social care.

Blair McPherson is author of Equipping managers for an uncertain future and People management in a harsh financial climate, both published by Russell House

The NHS should resist the American way

25 March, 2014 Posted by: -

The US: the land of marketing over substance, where everything is oversold and routinely underdelivered, has done a fantastic job of convincing us that they do it better.

‘Visiting the US, I am struck by the difference between the advertised price of any goods or service and what you pay’

British politicians look to the US for inspiration, particularly on how to win elections. The business community has also bought into the idea that US companies are more competitive and efficient. In fact, we have all been sold the idea that the way to prosperity is competition because it promotes choice and efficiency. This is such a sure-fire winner it can even work in the NHS, should we persist in the belief that the state should run health insurance and services rather than simply letting the market do what it does best: meet demand.

If people want good healthcare they will pay for it. The result in the US being that the government introduced reforms to try and address the fact that a third of Americans didn’t have any health insurance, mostly due to it being unaffordable. Like most insurance, when you most need it, you can’t get it.

Visiting the US, I am struck by the difference between the advertised price of any goods or service and what you pay, be it a meal out, the cost of hiring a car or a trip to the supermarket. I don’t suppose anyone likes paying taxes but the Americans like to rub your nose in it. The price you see displayed in a shop or restaurant is before the tax is added. Local tax is added at the till. In a restaurant they also add on a 18 per cent service charge ”for your convenience”. In other words, to save you doing the maths or considering tipping less. The result is you pay up to a third more than the price on the menu.

Winners and losers

No wonder Americans are so tax conscious. Tipping is, you soon learn, expected and rather than a means of expressing your appreciation. You signal your dissatisfaction by tipping less. Tipping is essential because the wages of staff are so low they rely on this element of their pay. The thinking is this keeps the staff on their toes, customer-friendly and attentive. In reality it means they keep seeking your confirmation that everything is alright.

‘In the US business is competitive and you play to win. This doesn’t sit easily with our public sector ethos’

The meaningless of this is shown if you say it isn’t. In America staff don’t seem to know how to react if you complain. The manager who previously eagerly responded to your enquires with reassurances and proud boasts about the service on offer is not available and the member of staff dealing with the public is too junior to enter any negotiation. Their standard response was often “I’ve only been working here three months”, which is the US equivalent of “I know nothing”. No wonder Faulty Towers was such a big hit in the US – and we thought it was because our customer service was so bad.

US TV’s 500 channels mostly showing repeats like Faulty Towers have twice as many breaks for adverts as we are used to and they are twice as long in duration. Doesn’t every one just put their favourite shows on series link and fast-forward through the adverts? Which is why American football is so suited to American TV, the action is live but stop-start, so lots of opportunities for adverts.

Sport is very popular in the US but have you noticed their always has to be a winner? There is no concept of a draw. And the popular sports like American football and basketball are all high scoring; a basketball game is won in the last seconds with one team scoring 80 points. The significance of this is the overlap with the business culture, which overflows with sporting metaphors. In the US business is competitive and you play to win. This doesn’t sit easily with our public sector ethos or the introduction of US private health insurance companies into the NHS.

A nice place to visit

The Stars and Stripes fly everywhere on public buildings and houses. Americans seem to find it necessary to assert their patriotism, maybe its because everyone was originally from somewhere else. I visited during the St Patrick days celebrations where every other person claims to be an Irish-American, they parade through the streets wearing green, drinking green beer, overlooking the river dyed green for the occasion. Is this where our discussions on what it means to be British are leading us, to salute the flag every morning in school but retain a cultural identity based on where our great-great-grandfather was born?

‘The culture is so different, which is also why we should not attempt to transplant their ways of doing things and expect it to work in the UK’

The motor car rules. No one walks, except in New York. Therefore cars are cheap, petrol very cheap. Remember the tax is added at the till so every American is reminded how much the government is adding every time they fill up. How many motorists in the UK could tell you what the government adds to a gallon of petrol?

The result is a lack of public transport and a smog problem in the big cities which is rarely mentioned but presents a very real public health problem. They dismiss it as sea fog, heat haze, even barbecue smoke; anything rather than except its pollution from their cars. Which makes it difficult for the city mayor to exercise the type of community leadership we are told elected mayors would be able to provide if we followed the US model.

If this all sounds anti-American, it is not intended to. It is a fun place to visit because the culture is so different, which is also why we should not attempt to transplant their ways of doing things and expect it to work in the UK.

Florida: the future of older people's care?

24 March, 2014 Posted by: -

I have seen the future. It is Florida, but it is not Miami or Orlando. It’s palm trees, white sandy beaches and the crazy golf of the costal communities. The future is full of old people.

‘I don’t know where the nursing homes are hidden or the very old and poor live’

Happy hour, 5pm-7pm, it’s people in their 70s and 80s sitting on bar stools drinking cocktails. In the future no one cooks, it’s cheaper and easier to eat out or get a takeaway. In the future no one walks. In the future there is only semi-retirement, older people work in supermarkets, but not on the tills; in hair salons, but not in nail bars; in information centres at the mall and at the post office. They are very good with elderly customers. They don’t work in restaurants or behind the bar. They do work in the many coffee shops.

Everywhere conversations are loud, is it the alcohol, the hearing impairment or just habit? People drink and drive but don’t go more than a couple of blocks and only drive at 25 miles an hour. They are happy to stop for pedestrians to cross the road. They are not in a hurry.

Side-effects in the sun

The adverts on all channels are about healthcare insurance, Alzheimer’s disease, hearing loss, diabetes and a cure for conditions that you didn’t know existed. Just ask your physician for a prescription. Not suitable for pregnant women, anyone with high blood pressure or a history of an existing heart conditions. Side-effects may include nausea, headaches, muscle pain, incontinence, constipation, dizziness and breathing difficulties.

They come to avoid the cold winters and grey skies but despite the sun they prefer to sit inside. They don’t smoke, have their own teeth and dress for comfort. They eat big meals, preferring quantity over quality, yet the majority are not obese. Maybe they only eat once a day. They live in retirement communities or neglected single-storey wooden houses on shady boulevards or dusty side roads.

Well the ones we see do. I don’t know where the nursing homes are hidden or the very old and poor live.

Middle managers need to stir it up

14 March, 2014 Posted by: -

It is not the sugar in the coffee that makes it sweet it is the stirring.

‘NHS leaders’ idea of change always seems to involve a restructuring where a lot of people have to reapply for their own jobs’

Stirring it up is part of my recipe for successful management. By stirring it up I mean agitating for change. Change has got a bad reputation of late, probably because it is seen as top-down: the government’s transformation of the NHS, the modernisation of the civil service and senior managements changes in the way services are delivered.

Agitating for change at work use to be botto- up. I don’t just mean unions pushing for better pay and conditions. I can remember when team managers were always pushing for change; they had lots of ideas for new services and just wanted the freedom and a little money to pilot their ideas. In fact, a lot of radical stuff went on under senior management’s radar.

Even when the cuts agenda meant management efficiency drives required changes, most of the ideas came from the front line. Change really only became a “bad thing” when it was to save money rather than improve services.

Not radical enough

NHS leaders’ idea of change always seems to involve a restructuring where a lot of people have to reapply for their own jobs, a group of well paid senior managers take generous redundancy packages only to reappear in another senior management post in the NHS, and the disruption distracts every one from patent care.

Leaders are only interested in strategic changes, a shift to community services, the centralisation of specialist services into centres of excellence, a restructuring to support commissioning, and an all singing all dancing computer system.

Simple changes like non-discretionary national minimum staffing levels on wards, increased number of consultant posts for A&E and the pharmacy being adequately resourced so patients don’t spend all day on the ward waiting for their medication before they can go home – these are dismissed as too expensive and not radical enough. Except, of course, they would facilitate better quality care, less bed blocking and fewer repeat admissions.

But that might mean we don’t need a top-heavy commissioning structure or all those competition lawyers.

Whatever happend to the battle against institutionalisation?

12 March, 2014 Posted by: -

What have Mid Staffordshire Foundation Trust, a residential care home for older people and a psychiatric ward got in common? Scandals about care practices, budget/funding problems and services run for the convenience of staff, not the needs of patients. In other words, the return of institutionalised care.

‘It was characterised by running the ward to suit the convenience of staff, not the needs of patients’

Institutionalisation was a big deal in the 1970s and 1980s. Patients on long stay wards were observed to gradually become over dependant on staff, to become compliant at the expense of their independence, to stop thinking for themselves.

Set in their ways

In response, long stay institutions were to be replaced by smaller, more homely units. Care values such as choice, independence dignity and respect were to be the principles informing how staff provided care.

Workforce

An unofficial staff culture existed

But of course it wasn’t just the patient who became institutionalised. Staff were often just as set in their ways, an unofficial staff room cultures existed within many institutions which was counter to the official culture. In extreme cases this included unsanctioned methods for dealing with patients who were considered uncooperative, demanding or difficult. In general, it was characterised by running the ward to suit the convenience of staff, not the needs of patients.

‘Budget cuts have seen staffing levels reduced, supervision less frequent, training opportunities reduced and a light touch inspection which was less effective in getting beneath the surface’

This staff culture has proved resistant to training and inspections but appeared to be overcome where staffing levels and supervision backed up the good practice covered in the training provided. Budget cuts have seen staffing levels reduced, supervision less frequent, training opportunities reduced and a light touch inspection which was less effective in getting beneath the surface.

Senior management’s preoccupation with budgets has been at the expense of promoting good care practices and the return of institutional care.

Love over fear in managing absenteeism

6 March, 2014 Posted by: -

Happy staff have less time off sick, so why when staff surveys report rock-bottom morale are absenteeism levels falling? The reason fewer staff are throwing a sickie is that employers have has introduced tough new policies and procedures to sack people with poor attendance records. So is it better to be feared than loved?

‘Employees are not happy. They are disillusioned with management; anxious about reorganisations and redundancies’

Happy staff are more productive, they take less time off sick, so organisations should take steps to increase employee’s job satisfaction. This is the recommendation from Investors in People following research into staff health and wellbeing.

The trouble is employees are not happy. They are disillusioned with management; anxious about reorganisations, redundancies and changes to working practices; they are frustrated by budget cuts, service reductions and efficiency targets. So the most effective way of reducing absenteeism is to introduce tougher policies and procedures to sack people with poor attendance records.

The research found that 54 per cent of workers say their boss does not care about their health as long as they get the job done. 

The research also showed that job satisfaction is directly related to the number of sick days as those who describe themselves as happy in their role are less likely to call in sick. Nearly three in 10 unhappy workers also say they embellish the truth about being ill.

Get tough

So if unhappy staff are more likely to throw a sickie and a high proportion of staff are unhappy, why are public sector organisations reporting success in reducing absenteeism? The answer lies in the type of absenteeism. People who skive take the odd day or two off work when they are not really too ill to attend but simply have had enough. The sickness absenteeism that has been reduced is long term sickness.

‘If you want to tackle absenteeism then change the perception that managers don’t care about the health and wellbeing of their staff’

In the past, people off sick for more than two or three weeks were allowed to drift with the result that a small number of staff were still absent for over six months with no incentive to return until they went on half-pay and in the knowledge that they would be paid for up to 12 months.

A “get tough” policy has resulted in a proactive response, which translates into sacking people after three months if there is no prospect of an immediate return. In practice a broken leg or an operation would result in a medical assessment with a realistic timeframe for a return to work agreed with the employee. If the diagnoses were depression or a bad back then neither the employee nor their doctor can offer a timescale for returning so their employment would be terminated. The result is a significant drop in the absence statistics.

Peace and love

But if you want to tackle short term absences love may be more effective than fear.

Paul Devoy, head of Investors in People, says: “Organisations need to see staff health and well-being as crucial to their business and staff retention. Our research shows that happier staff are less likely to take time off sick. What’s more, companies offering health and well-being perks will see real business benefits. Investors in People is encouraging businesses to consider how they treat their staff to ensure they have the happiest and most productive workforce.”

Another way of expressing this is if you want to improve your absence statistics, sack people once they have been off for three months. If, however, you want to tackle absenteeism then change the perception that managers don’t care about the health and wellbeing of their staff.

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