World at One09 November 2012
James Robbins: Should pay be linked to performance in the National Health Service? It can be a controversial question in any area of work but in the NHS it certainly is a controversial question. The health unions and the employers are meeting today and seem close to reaching a national agreement. It could mean that, for the first time, incremental pay rises won’t be given automatically just for turning up in the NHS and doing your job. The talks coincide with a new report from the think tank Reform. It argues that better better patient care requires a big culture change in hospitals. Our reporter Andrew Bomford has been to Salford Royal Hospital, where they’ve been trying out some new ways of working.
Andrew Bomford (AB): You can immediately spot Charlotte Barrett on ward H4, a urology and gynae ward, by her Post Office red uniform. She’s the ward matron, and she got a change from the blue – of a ward sister – to bright red when her ward got the top ranking for what they call a safe, clean and personal ward two years running. It’s a status the 42 wards here compete for vigorously, and 18 have made it so far even though, Charlotte says, it doesn’t mean any extra pay or rewards for staff.
Charlotte Barrett: It is a big deal. Providing good care is why we’re here. We have to be able to say and feel that we provide good care to our patients. It’s the reason that we get up and come in in the morning and look after our patients.
AB: The efforts of staff have not gone unnoticed by the patients, too.
Patient: Excellent. They’re very accommodating. The food has been great, and the care has been very good.
Patient 2: They keep you in the loop in everything, they’re all brilliant.
AB: Salford says it wants to be the safest hospital in the NHS, but it’s not something they’ll achieve without the buy-in of staff. It can’t be imposed top-down. So, here they’re trying to eliminate some of the Chinese walls between us (the staff) and them (the management). Take Pete Turkington, one of a new breed of clinical directors. He’s a consultant chest physician, who became a clinical director when they got rid of the old clinical directors and had an open competition for new ones. It’s a management job, which used to be a Buggins’ turn-type role rotated around the consultants. Some of them still complain, though, that it’s a job where you carry the can when things go wrong, but have little power to change anything. A point Pete does not deny.
Dr Pete Turkington: That’s the journey we’re on. Yes – I have accountability for the entire division. Do I have autonomy for the entire division at the moment? No. Do I expect it? No, not yet. I hope that, in time, that will come.
AB: So it’s a journey, which has some way to go. Elaine Inglesby is the executive nurse director, so is well and truly management, but she does at least two shifts per month as a nurse. She worked last Saturday on the renal ward. She says many on the shop floor like to think of us and them. After all, it gives you someone to blame.
Elaine Inglesby: I think it suits them for there to be a division. I think that has been the culture in the past. I think that it was a struggle for us in the beginning – that staff didn’t want us to get close to them. Now that culture is emerging here in this organisation, and I say emerging because I wouldn’t say we’ve reached our destination.
AB: It has not been plain sailing. Three clinical directors objected to the subjective way staff were being appraised. The system for assessing performance has been scrapped, and is being replaced with something new. It’s important to get it right because management here are linking pay rises to performance. Most NHS staff get an automatic average 3 per cent rise each year by moving up a pay point. Here they say pay rises should be earned. NHS employers and the unions are moving towards a national agreement on linking performance to pay, and a chief executive here, David Dalton, says it must happen.
David Dalton: We have the opportunity of doing something significantly different in the way that we match the rewards for staff with the contribution that they make. It has to be done with consent. People will be concerned about change and how this may affect them, and so the important thing is that we have open conversation about it and we reach agreement.
AB: In Salford, there’s at least tacit consent. But staff satisfaction here generally is high – it won’t be as easy elsewhere. But here the big lesson learned is the importance of taking staff with you. Happy staff means good, safe care for patients.
James Robbins: Andrew Bonford reporting. Joining me now to discuss the issues, Nick Seddon, Deputy Director of the think tank Reform, and Karen Jennings, Assistant Secretary to the trade union Unison. Karen Jennings, are you now ready to accept performance related pay?
Karen Jennings: I’m sorry, I haven’t come onto this programme to discuss performance related pay or the negotiations that are going on. Those negotiations are actually happening this afternoon and it would be inappropriate for me to comment on that. I am very happy to comment on the fact that Agenda For Change has already gateways in it, which means, provided you are getting a development review, that you need to demonstrate that to go through that gateway and get your next increment, that you’re performing as the trust would want you to perform and that the trust itself is enabling you to do that. So that already exists.
JR: But you do accept, Karen Jennings, the need for reform?
KJ: I accept the need for the NHS to continuously look at what it needs to do to ensure that it’s providing resources so that the staff can deliver good standards of care. The union has always accepted that it needs to reflect on those things and we have engaged through the Social Partnership Forum all the way along in terms of the sort of reforms that are going on. Not just in pay but in how services are delivered and it’s extremely important that staff are engaged in how those services are delivered because they know best.
JR: Nick Seddon of the think tank Reform, Karen Jennings seems to accept the case for reform.
Nick Seddon: Which is fantastic and can I say that the piece on Salford was also a wonderful exhibition of the kind of excellence in the system at the top end. What we’ve done in our report is look around the world, not just in the UK but around the world at world-class healthcare, at the very best examples where you are getting the highest quality at the best cost in terms of healthcare delivery. What I would say that perhaps goes a little bit beyond the package is that the system is very inflexible at the moment and it makes it harder for great leaders to emerge who employ people in the best way, to get the best out of their human capital. What we are arguing for in our report is for the system to be more flexible or at least for the government to mandate greater flexibility in the system. There are lots of incentives that you can provide - pay is one of them, but there are lots of different ways of celebrating excellence and being intolerant of failure. But we do want to see is a system that is high performance across the board and at the moment we don’t have that.
KJ: Can I just say that the Reform report is conflating two issues and that is the structure of the NHS and then they’ve thrown in the bit about pay and performance related pay. Now I actually think that this report doesn’t really address the issues it raises. For example they are recommending local commissioning and local contracts. Let’s not forget we have just gone through a £3 billion reforming process. What Reform is failing to address is that their recommendation that clinical commissioning groups could effectively commission primary care services for themselves. GPs are the clinical commissioning groups and therefore there is a real failure in this report to address the issues of the conflict of interest. In addition to that, it is suggesting that there should be no national oversight to those local contracts, and that seems to me to miss the point completely about business standards.
JR: Karen Jennings, isn’t your fundamental resistance to performance related pay, the idea that it actually just weakens the unions’ position in collective bargaining?
KJ: No, not at all. What we are concerned about in relation to pay in the NHS is that our Agenda For Change system that we have in place is a system based upon equality. It has got plenty of flexibility in it. It is a system that has enabled local initiatives such as Salford and many, many other hospitals to introduce all sorts of practice to enable staff to collaborate and to work together in the best interest of staff. I think that a national pay system will prevent industrial strife, it ensures that there is no poaching across local hospitals and anecdotal evidence across the USA or from India are not helpful examples of the sort of healthcare that the UK provides.
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