Published: 07/10/2004, Volume II4, No. 5926 Page 32 33 34 35

Policy movements like modernisation, case management and community engagement are not just abstract concepts - they mean people are working in different ways and becoming different people as a result.We talked to six people who exemplify some of the new careers NHS managers are leading.

JAYNE MOLYNEUX: CASE MANAGER

'You get close to people's lives, but It is important they do not become dependent'

The focus on chronic disease has created a huge interest in training primary care nurses to undertake proactive management of the most vulnerable elderly - the so-called frequent fliers who though small in number can account for a large percentage of hospital admissions.

The Evercare pilots run by UnitedHealth Group have grabbed the headlines, but arguably the very first case management nurse was Jayne Molyneux, based at the Castlefields health centre in Runcorn. She took on the role in 1999 after only three years as a primary care nurse, retaining some existing responsibilities as district nursing team leader.

She recently started working with the National Primary Care Development Team to help promote 'unique care nursing' to other primary care trusts. As a case management nurse, her workload varies hugely - from compiling admissions data to studying accident and emergency referral letters, liaising with hospital managers, talking to social workers and - perhaps most importantly - calling, visiting and supporting patients.

The direct patient contact is a big difference from previous jobs. 'I am more of a co-pilot - the patient flies the plane and I've got some emergency skills but I am not an engineer.You get close to people's lives, but It is important to maintain a balance so they do not become dependent.We negotiate a 'contract' at the beginning of what is being asked of both sides and we encourage patients to discharge themselves.'

She has a case list of about 50 people, although the average time anyone spends on it is only about seven weeks. One of the paradoxes about frequent fliers is that a relatively short intensive burst of care can transform their lives and aspirations. 'It is about building their knowledge of their conditions and increasing their confidence about managing it and using services that do exist.'

One elderly woman rang up after coming off the list the previous year. 'She wanted to refer herself to us for a short period because of some forthcoming surgery. As it happened, having worked with us, she decided not to proceed with it. That was entirely her decision, but it showed how much she had progressed in being able to manage her condition.

'As a nurse I had been used to patients who were very ill and working with them in quite short episodes with no time to think about pre-emptive strikes on their conditions. The new job was much more satisfying. 'As the relationship grew I felt I was mentoring GPs on developing packages of care and they were mentoring me on clinical issues.

'But your communication needs to be spot on, whether you are talking to a patient in their home or telling a consultant on a ward why someone would be better off at home. They are completely different situations and you have to be comfortable in both.'

SARAH GARRETT: MOBILE MODERNISER

'When I am away from home it is too easy to work every waking hour'

It is fitting to interview Sarah Garrett at London's Euston Novotel, sandwiched between railway stations. It is generally heaving with NHS managers - in, on the way to, or between meetings.

They all exhibit traits of what Ms Garrett exemplifies - the mobile 'moderniser'. By their Blackberries you shall know them.

National manager for the Modernisation Agency's pursuing perfection (P2) programme since 2002, she is the archetype for a type of manager that has emerged in the last few years. She works in a small non-hierarchical team with a range of trusts to broadly the same improvement agenda but often with quite different cultures and agendas.

She generally spends two days a week working from home, with the rest split between trains, hotels and people's offices.

A former management trainee with spells at three hospitals in the South West (including Bristol Children's Hospital at the height of the Kennedy inquiry into children's heart surgery at the city's Royal Infirmary), Ms Garrett joined the fledgling clinical governance support team in 1999. Originally intended to be two days a week, it quickly turned into 'four home/life-killing months in a hotel in Leicester'.

'There was no blueprint: it was a brand new idea and a brand new approach. I had one day in Leicester, but the rest was mobile across the whole of the South West.'

Joining P2, set up by Helen Bevan and Jo Bibby, she was again moving from quite a big team to an embryonic one.

'It was about developing something new with the four pilot sites. The first year could be frustrating because we were still thinking in terms of conventional programme management and in the second year we have tried to be less managers and more joint learners.

'In a complex system, a role like mine works by connecting with lots of other roles, adding value by helping people working in a range of operational roles to develop new ideas, new ways of doing things, and challenge them.'

She loves the lack of routine, the overview she gets from working with a range of trusts and the strength of relationships with a lot of bright people. 'But it would be a difficult job to do if you had a family, ' she says. 'One of the difficulties is getting a balance in work-life; when I am away from home it is too easy to work and be with colleagues every waking hour' - although she gives the impression she loves that, too.

The Modernisation Agency may be downsizing this year, but it will employ perhaps 100 improvement leaders in the style of Ms Garrett's job (a cadre she hopes to join). She could not imagine going back to a purely operational role in a large organisation. That said, her type of role is having an effect on 'client' trusts, fostering more flexible and less hierarchical cultures.

Does she feel she ever has to justify her job? 'Generally, people are only sceptical about modernisation when they haven't had any direct contact with it.

'But my grandfather is a GP and grandmother is a physio, so when I can convince them my salary wouldn't be better spent on nurses I'll know I've made a difference.'

MAUREEN BREEN: INDEPENDENT MANAGER

'The autonomy I have been given leaves me feeling I am really in charge'

'I can't wait for the men in hard hats to come in and start work on the building, ' says Maureen Breen, general manager of the planned independent sector treatment centre based at Burton Hospitals trust.

Ms Breen is a new type of manager helping to shape the future of the NHS. She has been employed by US-based firm Nations Healthcare for just under a year and says that she 'loves working for the private sector'.

Nations Healthcare has so far won contracts with the Department of Health to build three new treatment centres in Burton, Bradford and Nottingham, and Ms Breen has been in charge of setting up the Burton site since she was seconded from the NHS last November.

If all goes to plan, the project should reach financial close in November, building work is scheduled to start before Christmas, and the centre is set to open in March 2006.

Ms Breen admits that the decision to work for the private sector after 22 years in the NHS represents a very big jump. 'All through my NHS career I had been sceptical of the private sector, but It is a case of do not criticise something until You have tried it.'

She certainly knows the NHS. Qualifying as a general nurse in 1982 she progressed through NHS managerial positions and was finally charged with establishing and running the North West Midlands cancer network before being headhunted by the US company.

As general manager and previously as project director for the treatment centre, most of her time is spent working closely with the acute trust's treatment centre project team, local primary care trusts, and Shropshire and Staffordshire strategic health authority.

'Ninety per cent of my time is spent interfacing with the NHS. . .We have a meeting every two weeks which involves board representatives from the acute trust, the SHA, the PCTs and ourselves'.

She says that ultimately it is important to build a high degree of trust both with management and medical staff who will be seconded to the treatment centre.

She admits that although her switch from the NHS to the private sector meant giving up 'a good NHS pension and everything that comes with a public sector job', she has found the different ways of working a refreshing change. She says in the private sector one leaves behind the level of bureaucracy she has experienced in the NHS. 'The degree of autonomy I have been given leaves me feeling that I am really in charge.

'People constantly say the patient is at the heart of the NHS but the buildings we have mean this is not actually the case and nurses and clinicians are often just trying to swim upstream. The treatment centre will really put patients at the centre.'

PAUL HAM: SHARED SERVICES MANAGER

'PCTs do not understand what we do largely because we do our work so well'

Paul Ham is finance manager for the Patient and Practitioners' Services Agency for Devon.

The PPSA covers eight primary care trusts, 179 practices and around 800 GP principals and 100 ophthalmic practitioners. These two professions are the main focus for the PPSA's work.

Mr Ham has overall responsibility for all payments to contractors (some£120m last year) and is an acknowledged expert on GP pensions. The growth of personal medical services contracts reduced the amount the PPSA was responsible for dispersing by about£40m in 2003-04 as some of Devon's PCTs decided to make their own payments, but the figure will rise again as that work is being passed back across.

Mr Ham has a PMS manager working for him and a general medical services manager.

The bulk of the PPSA's work is with GP practices.Mr Ham initially worked for the Family Health Services Authority (an agency dealing with primary care). In the mid-1990s, the FHSA was merged into health authorities, but its function remained relatively intact.

Around that time, Mr Ham moved to the front line of the local health authority and dealt with the distribution of PPSA payments. Since 1993, he has led the team who administer the region's GP pension scheme. The scheme itself has changed dramatically, especially with new GMS contract.

At times, his GP pension work has felt rather like Banquo's ghost: 'It keeps following me around because I have the specialist knowledge. But I like it, because I get to help GPs on a one-to-one level on things personal to them - It is not just 'cash, cash, cash'. I like challenges, therefore the more change the better.'

Recent financial reforms have had big effects. 'Locality commissioning is really growing, which means more PPSA payments, as all the money goes through 'in hand' services.'

Mr Ham favours this. 'It encourages PCTs to take money out of secondary care and keep it in the primary sector - people will look for new ways of referring patients.We get involved in financial rewards for service, and there is more clarity with the enhanced services provisions in the new contracts.'

He predicts that payment by results is going to cause more upheaval, as will the quality measurement and outcomes framework (QMAF). Both will cause retrospective financial adjustment. Once the new QMAF system is in place in April 2005, it will tell the PPSA what money practices should have received, 'and we'll have to look at what we have paid against what the ultimate value of their achievement is'.

'Practices receive a third of the total value to which they aspire as an advance. April 2005 could be an interesting time for communication with practices.'

Mr Ham also sees two other key factors which could cause problems: GPs' seniority payments and GPs' pensionable pay. 'The latter is now based on profit forecasts for the year. Until practices' profits are known, we deduct pension contributions on the basis of forecasting, which will not be right to the pound.

Problems could arises when forecasts are too high, where we would then have to make a recovery, which would further reduce practices' profits, which affects pensionable pay!'

Mr Ham's conclusion is that 'PCTs do not really understand what we do largely because we do our work so well'.

'We do a very good job and are a very self-reliant organisation, which has tried to develop along with the changes to the rest of the NHS.'

SUE TALBOT: NEW PUBLIC HEALTH

'As a health visitor I never thought I would be negotiating with multiple agencies'

Sue Talbot is head of public health development and modernisation at Hastings and St Leonards primary care trust in East Sussex. She was also part of the successful health visitor/ school nurse (HV/SN) innovation programme.Ms Talbot is now moving on from the HV/SN work, as the project is no longer attached to GPs, but has moved to the community.

She points out that the borough of Hastings, although in the predominantly wealthy South East, ranks 27th on the national deprivation index.

'My big thing is empowering the community to do things for itself. It is about empowering local people and staff to look at local needs.'

In the past, she feels that health visitors were told what was happening and what they would do: Ms Talbot sees health visitors today as having been instrumental in developing more patient-centred services.

She comes from a health visiting background but says: 'I always had a sense that health visiting was about more than just the traditional, one-to-one basis. I always worked with communities, and wanted to do more of that.'

Ms Talbot worked locally with what was then the health authority on child development, looking at how it is affected by factors such as housing and environment.

'I was placed in a public health department and it made me understand, like a lightbulb coming on, that while engaging and supporting families matter, health visiting really belongs within public health, and as part of a spectrum of influences on lifestyle.'

Following that experience nine years ago, she felt it would have been hard to go back to traditional health visiting practice.

She next ran the health aspects of the Ore Valley community development project, starting in 1996.

'Residents of the Ore Valley region told us that they wanted to improve their health - but that they didn't know how to go about it.'

The project won the Queen's Nursing Institute Award for Innovation. Around that time, health visitors in the area started re-examining their practice and began questioning whether they could work differently to engage the community.

Ms Talbot observes that: 'Their asking these questions coincided with the announcements of the Innovations awards.

'When I successfully applied for that post, we looked together at how to take the broader public health role. The health visitors themselves did most of the work; I only facilitated and helped it happen.'

How does she see this work progressing? 'I have two agendas - the modernisation agenda and the tackling inequalities agenda. The former looks at how you take it forward within PCTs.

'I am privileged to be based in public health, but I sit across the PCT's whole range of community activities, neighbourhood renewal, children's' centres and SureStart.

'At the moment, We are looking to take SureStart good practice and spread it across the whole PCT patch, to those families not reached under the scheme, jointly funded by SureStart and the PCT.'

Has she found herself in unexpected terrain? 'Yes, as a health visitor I never thought I would be managing budgets or negotiating between multiple agencies.

Health visiting never used to teach those skills, but you learn as you go.'

Ms Talbot emphasises the importance of learning 'not to work hierarchically, but to take people with you and get the sense of ownership to communities'.

And presumably also to colleagues? 'Yes, absolutely.

Health visitors from our area will tell you that they own all the changes in their work'.

Ms Talbot is keen to emphasise 'the difference between management and leadership'.

'There really are differences: ones I've had opportunities to learn'.

She is mentor for the PCT's project workers (who can be funded from single regeneration bid money). Part of her job is now to ask these 'odds and sods' how their projects are going.

'It is also about me being able to pass on to them the knowledge I've gained from various bits and pieces.'

She concludes that her present role is 'about sharing skills, growing your own staff and about their development'.

'We are very clear that our PCT is about working with the community. Over time, our services will become more and more integrated.

'Our links with the voluntary sector and other partners are very good.We are quite a small PCT, but people are very committed to looking at local needs.

And I still really enjoy doing it.'

TRACY MARSHALL: PUBLIC SECTOR MANAGER

'We are making sure anti-social orders are not seen as the be all and end all'

The 'community' used to be a foreign country to the NHS. Old-style public health professionals in theory had links with local populations and other agencies, but there was often a gulf. This is quickly changing, driven by the priorities and planning framework and new statutory obligations on issues like crime.

Aas community health development manager for Tewkesbury and Cheltenham primary care trust, Tracy Marshall is one of a new breed. After a degree in social policy as a mature student and time as a voluntary sector manager, she joined Gloucestershire health authority in 2000 and took up her new role with the primary care trust two years later.

Her job is to liaise with other local agencies such as the council, police and community groups to make sure that health is part of local policy. In other words, it is to make the local strategic partnership work.

'There are lots of people who do not think they are anything to do with public health but have a big effect on the health of the community. It is difficult to engage with them and we are rethinking that at the moment.

We have to move away from beginning with a PCT's priorities and try to start with what their agenda is.'

Ms Marshall says one of the biggest dangers of community liaison is over-networking - rushing round meeting everyone and achieving nothing.

However, she says her current job creates more structured relationships. 'At the HA I knew a lot of names but not a lot of faces. And every time you 'met' the police, for example, it would be a different person.

Now I am talking to the same people.'

One of the key advantages over the HA is that she also has a local focus - in her case on two deprived areas in the PCT's two towns. 'The government wants us to focus on the bottom quintile - you can't do that if your geographical remit is too wide because in fact they tend to be concentrated in quite small areas.'

Knowledge in other agencies is also growing - not just what a PCT actually does (she finds many people have a pretty hazy idea of how the NHS is structured) but the links between health and other areas.

She points out that 10 per cent of the population with the worst health will suffer from 40 per cent of all crime, will have greater incidence of mental health problems and will have the lowest employment, the worst education.

Her seat on the crime and disorder reduction partnership means, for instance, making sure domestic violence is not ignored in favour of more high-profile crimes and 'making sure that anti-social behaviour orders are not seen as the be all and end all, ' and that resources are earmarked for regeneration initiatives.

A community manager sits on the border of the NHS, spending their time dipping their toes into other organisational cultures.

'You have to keep your feet in a lot of different camps, and although an NHS person and a police officer might agree on an end result our ways of getting there might be at odds. But I think not having a long history in the NHS myself actually helps.

'That old idea of public health as printing a lot of leaflets which told people what to do is not what today's PCT chief executives want from us.'

She cites the creation of a 'fair shares'manager post (the work-in-kind scheme developed by government): 'I can't think of a better example of this new way of working. It is being funded by the local strategic partnership and the county council's social services, was set up by me at the PCT and will be line managed by a manager in the borough council.'