health-adviser-issue-9

Health adviserI n s I g h t , f o r e s I g h t a n d p r a c t I c a l s o l u t I o n s

Health adviserI n s I g h t , f o r e s I g h t a n d p r a c t I c a l s o l u t I o n s I s s u e 9 / o c t o b e r 2 0 1 3

InsideThe new inspection regime

Moving beyond PFI debt

Better usage of health data

to listenLearningtrusts are all ears with innovative new engagement programmes

as the dust settles from a year of schismatic upheaval for healthcare, the framework of a new system is emerging.

greater engagement with patients and staff is now a must, both allowing organisations to identify areas of weakness and make economic improvements, as we explain on page 6. This response should help as a new inspection regime is rolled out across the country, as we find on page 10.

nevertheless, further changes will be necessary. a wealth of underutilised data could be the key to significant efficiency savings. We look at how this might work on page 20.

however, the finances of some trusts will remain precarious due to pfI deals. on page 16 we examine the root causes of this issue and look at possible solutions.

In fact, the need for pfI may fade as more distributed community healthcare becomes popular, something that duncan selbie, chief executive of public health england (phe), says on page 12 should be a future focus of wellness.

such changes may be more gradual than the recent rapid recasting of uK primary healthcare. but careful preparation and good advice will be needed to thrive in this new environment.

Welcome

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Nigel Montgomerysector head of health and partner

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2 www.dacbeachcroft.com DAC Beachcroft

Executive agendanhs It spend; competition commission private healthcare findings; tupe consultation; and dac beachcroft appointed to nhs la panel.

Cover storyLearning to listenThe nhs has been slammed for ignoring the views of staff and patients. but engagement is now a priority, as demonstrated by innovative new programmes.

A new inspector callsThe nhs is reeling from a year of scandals, inquiries and reforms to its quality assurance systems. a new inspection regime is both a response to these concerns and the latest change trusts must deal with.

A perfect partnershipduncan selbie, chief executive of public health england, argues that a new approach is needed to tackle inequalities in health and life expectancy.

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PFI financingpfI projects have helped to build more than 100 new hospitals, but are now synonymous with serious financial burden. how can trusts deal with the debt and what are the other options for financing?

Making the dataa limited capability among hospital boards and leadership to use healthcare data constrains the scope to drive improvement. greater attention will be needed to realise the benefits.

In practiceemploying new staff on a cut-down version of agenda for change is perhaps the only way that substantial sums can be saved on employment costs without unacceptable legal risk.

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Contents

Health Adviser is a dac beachcroft publication.

publishing services provided by grist, 21 noel street, soho, london W1f 8gpPublisher Mark Wellings; Editor sam campbell; Art director andrew beswick; Proofreader alan friedler; Commercial director andrew rogerson. Telephone +44 (0)20 7434 1447 Website www.gristonline.com

Cover image Kerry lemon Illustration Printed burleigh www.burleighpress.co.uk Brand consultancy 3 fish in a tree www.3fishinatree.com

If you would like to discuss any of the issues raised in this magazine please contact nigel Montgomery on +44 (0)117 918 2321 or your local dac beachcroft office.

for media inquiries please contact the press office on +44 (0)20 7894 6655.

dac beachcroft llp is a limited liability partnership registered in england and Wales (registered number oc317852) which is regulated by the solicitors regulation authority. We use the word ‘partner’ to refer to a member of the llp, or an employee or consultant with equivalent standing and qualifications. a list of the names of our members is available for inspection at our registered office, 100 fetter lane london ec4a 1bn. The information contained in this magazine is for general information only based on english law. The contents of this magazine do not constitute legal or other professional advice. readers should seek appropriate legal guidance before coming to any decision or either taking or refraining from taking any legal action. If you have a specific legal question, you should address it to one of our lawyers by contacting the relevant partner identified in this magazine, or on our website www.dacbeachcroft.com.

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Health Adviser / October 2013 3DAC Beachcroft

Executive agendaemerging issues for the health sector

NHS IT spend needs procurement, contracting focusThe government is set to invest £1 billion on upgrading nhs It systems, according to reports in the media.

announced by the health secretary, the cash boost to nhs technology will enable doctors and nurses to share access to the electronic records of patients.

The upgraded It systems, which the government envisages will help improve patient care, will also enable people to go online and book gp appointments, order repeat prescriptions (by March 2015) and access their own gp records.

“This funding seems certain to help fuel the continuing trend of increased numbers of local procurements being run by nhs organisations for clinical It systems,” says andrew rankin, health and technology specialist lawyer at dac beachcroft. “nhs england’s ‘safer hospitals, safer wards’ vision recognised a need to give organisations the right tools to make sourcing decisions.

“It will remain important that with this new funding, procurement and contracting best practice is pooled and made available to nhs organisations, to help them effectively deliver procurement processes and deals that are robust and a good use of public funds.”

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Provisional findings on private healthcare market releaseda recent investigation by the competition commission (cc) focused on the distortive effects of hospital market power and the high barriers to entry into the private healthcare market.

These barriers were mainly found to be a consequence of the high sunk costs connected with establishing a new hospital and the large economies of scale which existing hospital operators enjoy, relative to the size of local markets, says alexandra von Westernhagen, competition expert at dac beachcroft. Incentive

schemes offered to consultants (which have been found to distort referral decisions), a lack of information on hospital/consultant outcomes, and a lack of information on, in particular, consultant fees were highlighted.

The cc also published a notice of possible structural and non-structural remedies, says von Westernhagen. “however, it has admitted that it has not been able to identify a potential remedy which may address the issue of high barriers to entry to the market.”

The final report is expected in March 2014.

Best practice must be pooled and made available to NHS organisations

Alexandra von Westernhagen: “No potential remedy identified”


Professor Keri Thomas, National Clinical Lead for the Gold Standards Framework (GSF), presents her case …

Positive outcome for TUPE consultation

DAC Beachcroft appointed to NHS LA Panels

ExECUTIvE AgENDA

The government revealed the changes to be made to transfer of undertakings (protection of employment) regulations 2006 (tupe) on 5 september further to its review of employment law.

dac beachcroft was one of 178 parties to submit a response to the consultation on the reform of tupe earlier this year.

“The government appears to have listened to the responses to the consultation process and has, sensibly, revised some of its proposed changes,” says Zoe Wigan, partner in the employment and pensions group at dac beachcroft. “The main and welcome outcome to the consultation is that the ‘service provision change’ regulation – one of the provisions governing whether or not tupe will apply – will be retained, but amended to clarify that the activities carried on

after the change in service provision must be ‘fundamentally or essentially the same’ for tupe to apply.

“additionally the employee liability information provisions will not be repealed as was originally proposed. These provisions impose an obligation on the

outgoing employer to provide employee information to the incoming employer. This information will now have to be provided at least 28 days before the transfer, rather than 14 as is currently the case. This will give the incoming employer more time to prepare for the transfer.

“The changes overall are sensible, but not seismic. The changes to be made are generally pragmatic and will hopefully make the tupe process a little less complex. This is good for businesses.”

dac beachcroft has been appointed to all three legal panels of the nhs litigation authority (nhs la).

The firm’s health sector team has secured places on the body’s separate clinical liability, non-clinical liability and healthcare, regulatory and disciplinary panels on a four-year term. The appointments took effect from 28 May 2013.

Matthew Mcgrath, clinical risk partner, led the team for dac beachcroft with support from nigel

Montgomery, head of the firm’s health sector, and health partners david Weatherburn and corinne slingo.

“We are delighted to have the opportunity to continue our work with one of our key clients, the nhs la,” says Mcgrath. “This is

a great achievement for the firm, the groundwork having been laid by the fantastic work of my colleagues across the country.”

There is a pressing need for proper end-of-life care in Britain – although much progress has

been made, we are still unable to ensure that people can live and die well in this country. I was saddened to see the Liverpool Care Pathway (LCP) go: for the most part it delivered excellent care.

The GSF programmes in end-of-life care, one of the NHS-recommended models of best practice, are a vital element of end-of-life care in the community and increasingly in hospitals, enabling earlier, more proactive care to ensure we also get it right in the final days. The GSF guides healthcare providers to identify those nearing the end of their lives at an earlier stage, often before they get to hospital, and strives to ensure that they can die in the place they want with the care and treatment of their choice. These ‘gold’ patients can contact their doctors faster, get prescriptions faster, get extra benefits, and they are flagged up when re-admitted to hospital so staff know they need to think pre-emptively about their end-of-life wishes.

Earlier anticipation and planning allows community services to be tailored. For example, drugs could be administered to keep a patient pain-free at home, both offering the patient and their family a more pleasant experience, and keeping a hospital bed free.

The time just before death is important, offering unique opportunities for reconciliation. Clinicians and institutions must recognise that death itself is not a failure; a bad death is a failure, and there is more we can do to get this right for everyone. Raising the profile of end-of-life care may be one of LCP’s greatest legacies.

Find out more at: www.goldstandardsframework.org.uk

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The expectation is that health providers embrace far more innovative systems of gaining feedback. Nigel Montgomery, Sector Head of Health and Partner at DAC Beachcroft, page 6

Zoe Wigan: “The changes are sensible, but not seismic”

Matthew McGrath: “A great achievement for the firm”


The NhS haS of laTe beeN lambaSTed for NoT listening to patients and staff, or else failing to act on their concerns. What should have been an overriding priority of care has been muddied by financial or other targets.

recent reports have highlighted the need to draw on the untapped reservoir of knowledge and experience gleaned by staff and patients. or as US health safety guru Professor don berwick put it: “engage, empower, and hear patients and carers at all times.” The NhS is already reacting.

“organisations actively listening to their patients, and using that feedback to improve the quality and safety of services is a key message that underpins a number of the reviews and reports this year,” says Nigel montgomery, Sector head of health and Partner at daC beachcroft. “In years gone by, this would be little more than having a complaint process, but in 2013 and beyond, the expectation is that health providers will embrace far more innovative systems of gaining feedback from patients and families, and that the feedback will demonstrably affect change and drive improvement. We are seeing truly fascinating approaches to the issue of gaining feedback from patients and staff, and I fully expect further innovation in the coming years as part of the overarching push to maximise quality in healthcare.”

goldfish bowlPatients and service users, and their families, friends and advocates know immediately if something is not right, as the department of health pointed out in their response to the francis report on mid Staffs. but how can their views be heard?

New systems need not be complex or onerous to be effective. Great Western hospitals NhS foundation Trust, for example, is already extending the friends and family Test (ffT) launched in

april this year beyond the mandatory areas of acute inpatients and those who attended a&e. The ffT asks patients if they would recommend a particular ward or department, and at Great Western

hospitals, they have now rolled it out to minor Injury Units, community inpatient wards, maternity services (ahead of the national requirements) and are one of the first trusts to launch the scheme in outpatients. “We want to be able to get near real-time information about what is going on. Patients can fill in paper cards in the Trust’s hospitals, scan a Qr code, or go online to give us their feedback. We’re trying to make it as quick and simple as possible, meaning busy members of staff do not need to go through too many steps or systems,” says rob mauler, Great Western hospitals’ head of Customer Services.

Analysishowever, collecting qualitative and quantitative data is just the beginning. feedback is of little worth without analysis and action.

“engaging with patients to seek their views as to service provision is an essential part of monitoring and improving the quality of patient care,” says Tracey longfield, Partner at daC beachcroft. “however, this needs to be a meaningful process resulting in action being taken by the organisation. Through the analysis of patient feedback, common themes can be identified and used to modify the way in which patient care is delivered. Ideally, patients should be offered the opportunity to provide their feedback in a variety of ways as some patients prefer to contribute anonymously and others respond better with face-to-face contact. Small changes can make a big difference to the patient experience and do not have to be costly to the organisation.”

Some Trusts are giving staff an insight into the patient experience using the Goldfish bowl programme developed by NhS elect. a forum invites patients to discuss progress, complaints or the positive side of their experiences. Staff sit and

The nhs has been slammed for ignoring the views and pleas from staff and patients. but Mark gould finds that engagement is now a priority, as demonstrated by innovative new programmes.

to listenLearning

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Engaging with patients to seek their views as to

service provision is an essential part of monitoring

and improving the quality of patient care.


health,” he says. “Sharing PedIC data with patients and commissioners has allowed Slam to work with service users to shape the care they receive, but it also provides a quality measure for the local Clinical Commissioning Groups (CCGs) and specialist commissioners so they can also contribute to improved care.”

Johannsen-Chapman says PedIC is versatile, for instance offering insight into how a team is delivering against performance criteria, or how it is performing demographically against different populations. “When we look at care plans, for example, as far as we are concerned, we are 100% compliant,” he adds. “but when you ask some patients they might say ‘I haven’t received a care plan’. If they know they have a care plan then the relationship is a good one and we also know that we need to work much more closely with the confused and vulnerable who don’t.”

Staff of correctionhealthcare providers have a duty to staff and ‘end a positive and reassuring sign ... that they will be heard without fear of punitive action’, the bma argued in their response to the francis report. Certainly, their unique viewpoint is essential in identifying problem areas and deciding what can be done.

PedIC’s cousin SedIC (in development), the staff experience data information centre,

listen but do not participate. after the patient session staff are invited to discuss what they heard and suggest changes.

dedicated, integrated solutions can offer a detailed picture. With almost 300 teams or units caring for 36,000 patients across many physical locations, South london and maudsley NhS foundation Trust (Slam) is the biggest mental health and substance misuse service in the UK. Slam asked health sector IT design company fr3dom health to create a single system for all teams and patients. The result is PedIC, the patient experience data information centre. Teams carry out patient experience surveys, with questions designed with the help of service users, every quarter and load the findings onto PedIC, which are then analysed by fr3dom health. Surveys are either electronically uploaded into the system or hard copies can be sent by freepost for analysis.

dr ray Johannsen-Chapman, Slam’s Strategic lead for Patient and Public Involvement, says the data are fed back to clinical teams so they can look at ways of solving problems and improve services. Three areas have been suggested for improvement – feeling safe on the wards, medication information, privacy and dignity.

“It became clear that, though incredibly important in any healthcare setting, these themes were particularly pertinent to mental

Lessons from the service industrya common gripe with nhs care is a perceived poor level of service. great Western hospitals is developing a vision inspired by the private sector where patients need not battle through a plethora of departments, call-waiting messages or leave frustrating voicemails. The trust wants to make booking appointments, providing service suggestions or even making a compliment as easy as possible and with the fewest number of people or departments involved.

rob Mauler, great Western hospitals’ head of customer services, says healthcare should offer the kind of modern service that patients expect in other areas of their lives. “I came to the nhs from the audit commission and I was in a totally alien situation. people in the nhs didn’t use plain language so people often had difficulties in understanding. I hope that being new to the nhs I’ve been able to look at it from a different perspective and help improve services for all our customers.”

rob Mauler is currently working with his colleagues to develop a brand and ethos at great Western which aims to give service users the same outstanding level of service when using any of the more than 40 sites they operate. “It’s about offering a modern service along the lines of an organisation like first direct where you don’t need to go through 15 different processes or departments.”

is one way for staff to have their say. This online service would allow staff to speak anonymously about problems in one specific team or along one care pathway. To increase the likelihood of a completely frank expression of views, there is no way to identify wards or unit levels.

To ensure the higher echelons of the Trust are hearing patient voices, a Patient experience Group (PeG) has been established which is chaired by the Slam’s medical director, martin baggaley. following francis, Slam are looking to re-develop PeG to include representatives from local third-sector organisations, service users and staff. “PeG will be a powerful group that is part of a new flatter hierarchical structure, where top-down and bottom-up share an equal voice,” says Johannsen-Chapman, which will ensure a speedy flow of intelligence and insight can be passed ‘from the ward to the board’.

The Trust also uses link workers, many of whom are former service users, to talk to patients during ward community meetings about their experiences and feed this back to ward managers and staff to see where improvements can be made. link workers and the Patient and Public Involvement (PPI) team, alongside the inpatient ward staff co-produced improvement plans looking at specific themes safety, medications and equity.

link workers’ reports are shared with units or wards, which agree a set of changes that are monitored over the year. If the quality improvements are achieved, a financial bonus agreed with commissioners through the Patient experience Commissioning for Quality and Innovation (CQUIN) framework is paid.

Quick wins acting on the findings is the final piece of the puzzle. addressing some problems need not be overly difficult or expensive. Some may not even be directly related to healthcare (see box).

Croydon health Services NhS Trust is the first NhS organisation in london to have formally adopted a new way of working. listening into action (lia) is a pioneering national initiative developed by management consultancy optimise limited that actively seeks to make the concerns and ideas of staff the starting point for change. The staff

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refurbishment. The lia maternity Team reported that the environmental improvements have made a positive contribution to women’s postnatal experience and on the pride and morale of staff.

Patients attending the Trust’s Cardiac rehabilitation Service previously had to share the waiting area with staff on the busy ground floor of Shirley house at CUh, where all training takes place. Now a dedicated patient waiting area created from a vacated office means patients can wait in a quiet area with more privacy.

The achievements have stimulated a second wave of lia which will see changes in women’s services, the Trust’s chest clinic and health records. “Part of the inspiration for lia was knowing that more could be done to improve patient experience and that by asking staff what support they needed, we could make changes with real impact,” says lia Programme director mike hayward from Croydon health Services NhS Trust. “The quick wins from lia are already taking effect and I look forward to seeing how we can build on this.”

hayward adds: “delivering consistently good care means meeting national standards and most importantly asking patients and staff about new ways we can put high quality patient care at the heart of what we do. Since we started we have said to staff that this is your workplace and that your voice, your views, on driving improvements matter.”

Mark Gould is a health journalist and regular contributor to The Guardian’s Society supplement.

engagement scheme saw 15 teams chosen to develop new ways of working to improve every aspect of the patient experience.

maternity, Workforce development and the emergency department were among those sharing details of how they are changing the way they work, following staff conversations. Changes encompassed the physical environment, the information they share with colleagues and the wider Trust and the use of technology to better patient services.

highlights include the opening of an emergency dementia zone, changes to the way medication is given to patients so that they can leave hospital as soon as they are ready, and work to transform the

musculoskeletal Clinical assessment and the Triage Service.

They heard about a series of ‘quick wins’, a series of high-impact, highly visible and sometimes very simple improvements, such as putting paintings on hospital wards and setting up a portering station at the front entrance of Croydon University hospital (CUh) to escort patients into the hospital and to the nearest bus stops.

These relatively modest (and cheap) changes go a long way to convince patients and staff that the Trust is in earnest about listening and acting. New comfy reclineable chairs on mary Ward at CUh allow partners to stay overnight close to their new baby. The ward has undergone a complete

To discuss the issues raised in this article, please contact Corinne Slingo on +44 (0)117 918 2152 or [email protected]

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Nigel MontgomeryI fully expect further innovation in the coming years

Tracey Longfield Through the

analysis of patient feedback, common themes

can be identified

Mike Hayward By asking staff

what support they needed, we could

make changes with real impact

Small changes can make a big difference to

the patient experience and do not have to be costly to the organisation.


over The PaST year, for NhS orGaNISaTIoNS, The ‘tsunami’ of the francis report has been refined into the ‘bottle of filtered water’ of the berwick review, says Corinne Slingo, Partner at daC beachcroft. “We began with the furore of a huge public inquiry that has had a massive cultural impact but less effect in terms of material change to the regulatory landscape. Gradually, over the year that has been distilled down to actual actions that can really make a difference. berwick has very few recommendations but all of them are achievable.”

one of the first consequences is a new hospital inspection system headed up by Professor Sir mike richards, who was appointed Chief Inspector of hospitals in July. “In September, we introduced radical changes to the way hospitals in england are inspected. We have created larger inspection teams, headed up by clinical and other experts including trained members of the public, who will inspect key acute services for longer than ever before. Inspections will be supported by an improved method for identifying risks and with much more information direct from patients and their families, and

hospital staff. We hope that this will allow us to get a much more detailed picture of care in hospitals than has ever been possible before in england.”

The first wave of inspections is focusing on 18 NhS Trusts. “While our new style of inspection will still underpinned by regulation as set by the government, we have restructured our investigations around what matters most to patients – are the hospitals safe, effective, caring, responsive to people’s needs and well-led? Together with a new ratings system, we believe this will clearly present our findings to providers, as well as to those who use the services.”

as Chief Inspector of hospitals, richards says he needs to be completely open about where good and poor care is being delivered. “There is too much variation in the quality of care patients receive – poor hospitals will need to up their game and learn from the best. I will not tolerate poor or mediocre care.”

Ahead of the gamea key element of the new inspection regime includes consideration for whether the organisation is ‘well-led’, which goes to the heart of robust clinical and corporate governance systems, including being able to demonstrate compliance with a duty of candour arising from serious incidents. Slingo believes that most NhS organisations have little to fear on that element as they have already made many of the changes, especially in the area of transparency. “There already seems to be an immediate acceptance that following a serious incident organisations need to be as candid as possible.”

The CQC commitment to the involvement of specialists is a major improvement in the inspection process, she adds. “In the past there has been concern about not having the right eyes doing the inspecting. The specialist inspectors mean the risk of single inspector bias is reduced because you will have a broader cross section of people reviewing service quality, including clinicians, nurses, inspectors and service users. The impact however of having inspection teams of 20–30 people spending a minimum of two days on site, across multiple site

inspector callsA new

The nhs is reeling from a year of scandals, inquiries and reforms to its quality assurance systems. a new inspection regime is both a response to these concerns, and is the latest change trusts must deal with, Mark hunter finds.

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Triggers and surveillance indicators�• avoidable infections (such as Mssa, Mrsa and e-coli)�• notifications of deaths, severe and moderate harm, and abuse�• reporting of ‘never’ events�• deaths in low-risk situations�• mortality rates in various health care areas�• results of access measures�• information from patient and staff surveys�• information from the ‘Your experience’ form on the cQc website�• complaints


INSPECTIoN

To discuss the issues raised in this article please contact Corinne Slingo on +44 (0)117 918 2152 or [email protected]

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organisations, followed by a complex triangulation of evidence and perceptions gathered by that team, will be significant for all regulated organisations.”

big questions remain over what follows inspection results; the CQC will gain new powers around Warning Notices, which will have the potential to trigger not only enforcement by the CQC, but also a

‘read across’ to monitor’s powers under s.65 of the NhS act 2006, with new powers to initiate interventions, based on quality concerns following non-compliance with CQC warning notices. beyond both streams of potential enforcement ‘bite’, sit licence conditions based on quality issues, and potential prosecution for breaches under CQC regulations – augmenting those which currently exist, and moving the risk of sanctions forward to cover non-compliance with future fundamental standards, failure to comply with a duty of candour, and (if the CQC gets the powers they seek in their consultation), the power to move to prosecution without a warning notice. Testing times lie ahead for all.

There already seems to be an immediate acceptance that following a serious incident organisations need to be as candid as possible.

2013: a year of change in healthcareFEBrUAry The francis report on failings at the Mid staffordshire nhs foundation trust makes 290 recommendations in five key areas:�• Improving the structure of ‘fundamental

standards’ – causing death or harm by failing to comply with these standards should be a criminal offence�• transparency – a ‘duty of candour’

should be made statutory for all hospitals with gagging clauses banned�• nursing – nurses should deliver

‘compassionate care’ and healthcare assistants should be regulated�• leadership – a ‘common code of ethics’

should ensure strong and patient-centred leadership in the nhs�• Information – giving false statements on

compliance with standards should become a criminal offence

MArCHThe government’s initial response to the francis report proposes a number of ‘radical new measures’ including:�• ofsted-style ratings for hospitals and

care homes�• a statutory duty of candour for

organisations registered with the cQc�• a new regulatory model under an

independent chief Inspector of hospitals�• to consider legal sanctions against healthcare

providers who knowingly give misleading information to patients or relatives�• new ‘fundamental standards’ to outline

what patients can expect of the nhs

APrILThe cQc announces radical changes to its operation. These include:�• appointing chief Inspectors for hospitals

and social care�• inspections to be based on five

questions – are services safe, effective, caring, wel-led and responsive to people’s needs?�• bigger inspection teams led by specialists

in the areas of care they are inspecting�• introducing a clear action plan for failing

nhs trusts�• strengthening the protection of people

admitted under the Mental health act�• publishing ratings of services

MAyThe government publishes the care bill incorporating its response to the francis inquiry, which:�• sets out ofsted-style ratings for

hospitals and care homes�• gives powers to the new chief

Inspector of hospitals to speed up the response to problems�• makes it a criminal offence for health

and care providers to supply false or misleading information

JULychanges in the way hospitals in england will be inspected are announced, including:�• bigger inspection teams, headed up by

specialists and including trained members of the public�• longer hospital inspections, covering

acute services and eight key services areas�• a new surveillance framework�• a mixture of unannounced and

announced inspections

AUgUSTprofessor don berwick publishes his report on patient safety in the nhs in england. Its ten recommendations are:�• The nhs should embrace an ethic of

learning�• leaders should place patients’ safety at

the top of their priorities�• patients should be involved in all levels

of healthcare organisations from wards to boards�• staffing levels must be sufficient to

provide safe care�• all healthcare professionals, including

managers, need to master patient safety sciences and practices�• leaders should support learning within

the nhs�• transparency should be ‘complete,

timely and unequivocal’�• safety and quality monitoring should

seek out the patient and carer voice�• supervisory and regulatory systems

should be simple and clear�• criminal sanctions should be

extremely rare


A perfect

dUNCaN SelbIe haS JUST had oNe of hIS flagship projects pilloried across the national media and described as a waste of time by international health experts and the leader of the country’s GPs. yet the softly spoken Chief executive of Public health england (Phe) seems pretty unperturbed, and as enthusiastic as ever.

The Phe has responsibility for delivering NhS health Checks, the £300 million programme that aims to invite all 15 million people aged 40–74 to check out their risk of developing future health problems like diabetes or stroke and take preventative action to reduce that risk, such as lifestyle changes.

Phe took over responsibility for implementing the programme this april with local authorities being asked to focus on 20% of 40–74-year-olds each year over the next five years. In a letter to the Times just before Selbie’s interview, researchers from the influential Nordic Cochrane Centre in

denmark said its analysis of 14 trials with a total of over 182,000 participants “could not find any beneficial effects of health

checks, whereas they likely lead to unnecessary diagnoses and treatments.” They also slammed the programme for a scanty evidence base.

dr Clare Gerada, Chair of the royal College of General Practitioners, said the routine checks should end as patients were being needlessly worried and family doctors were wasting time that should be spent treating sick people. Selbie thinks a while before acknowledging that the evidence base was not complete, something he says was recognised in a joint paper with NICe and the local Government association when health Check was re-launched. “There haven’t been conventional double-blind randomised control trials – which there aren’t for a lot that we do in the health service.”

however, he says that there is evidence for identifying people with risk factors such as high blood pressure and high cholesterol and encouraging them to make lifestyle changes to

a new approach is needed to tackle inequalities in health and life expectancy, argues duncan selbie. he stresses to Mark gould the importance of local government involvement and cooperation to curb poor health and promote wellbeing.

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ForESIgHT INTErvIEW

If you think about the last 30 years I don’t think you can say we have done an awfully good job in terms of the health inequalities that exist across the country.


about a 20% contribution to length of life and life without misery.”

The academic michael marmot (who led a Government review looking at how to improve individual and societal wellbeing) and many others have talked at length about the wider contributors to wellbeing, notes Selbie. he feels public health has a massive contribution to make: “I think it’s where the action is for the next decade. There will be challenges but public health will have more fun in the next ten years than they have had in the last 40.”

obesity is a big challenge – around a quarter of children leaving primary schools are now overweight or obese. What can be done about children eating from fast food outlets, for instance? “What can the health service do? Nothing. What can local authorities do? a lot. I would expect local authorities to be increasingly aware and concerned about the proximity of fast food to schools, their opening hours, and concentration – equally with the sale of high-volume cheap lagers and so on.”

Selbie nods in agreement about ideas such as council tax concessions for no-car households or for planting trees. he feels standardised cigarette packaging will become law sooner rather than later. “Naturally, we, as a public health agency, were disappointed that the Government decided that it wasn’t going to happen yet. but the Prime minister and the Secretary of State made it plain that they will be open to further evidence.”

but what happens if a radical local authority wants standardised packaging on cigarettes before this decision is made, or wants to ban super-strength lagers and ‘white’ ciders, or does something else that doesn’t chime with national goals? “If a local authority takes the view, as some have, to ban super-strength lagers we would support them. others are looking at speed restrictions in residential areas; we would definitely encourage local initiative.”

Pulling togethermotivational techniques to bring people together are part of Selbie’s armoury. “I was recently the Chief executive of an acute teaching hospital where we had a seminar with

reduce them. Indeed, the importance of lifestyle and cooperation at a local level is of paramount importance for Selbie.

A new approachSince april Phe have been given possibly the toughest remit of any public body: to improve the health and wellbeing of the public. There are specific targets for cutting smoking and obesity, improving sexual health, and, perhaps toughest of all, reducing social isolation. Public health departments have moved from the NhS into 152 local authorities that will work with the NhS via local health and Wellbeing boards. Selbie is nothing but happy with the move.

“local government has a democratic mandate, it’s responsive, understands communities, and can make the biggest impact in improving health,” he says. “a partnership between local authorities and the NhS, working through the health and Wellbeing boards, sharing the same priorities and a similar understanding of the evidence, seems a stroke of genius to me. We started like this in the 1950s, forgot about it in the 1970s and remembered just in time.”

he is adamant that the NhS alone cannot deal with obesity, the demographic time bomb and society’s increasing unhappiness. “If you think about the last 30 years I don’t think you can say we have done a good job in terms of the health inequalities that exist across the country – the further north you go the worse they become. I don’t think any individual discipline can hold a veto about getting in before the illness happens. We have already tried the model of waiting until you are sick and then coming to see us.”

WellbeingSelbie takes a holistic view, stressing the widest determinants of wellbeing. “Three words you always hear: jobs, home and friends. Wellbeing is not about the distribution of a&e departments or how we ration gastric band operations.”

medics and surgeons have their place, he says, but from a past career as the Chief executive of a large acute Trust he knows that “the management of disease makes at most

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I don’t think any individual discipline can hold a veto about getting in before illness happens. We have already tried waiting until you are sick and then coming to see us.


Duncan Selbie in brief

Education: • Grove Academy, Dundee • Diploma, Institute of Healthcare

Management (1991) • MSc Health Management, South

bank university (1994)

Career: • 2012–present – Chief Executive

of public health england• 2007–12 – Chief Executive of

brighton and sussex university hospitals

• 2003–07 – Director General of programmes and performance for the nhs and subsequently the first director general for commissioning, department of health

• 2001–03 – Chief Executive, South

east london strategic health authority

• 1997–2001 – Chief Executive, south West london and st george’s Mental health nhs trust

• 1991–97 – Director of operations, pathfinder Mental health services, springfield hospital, south West london

• 1988–91 – General Manager, Wandsworth community services, south West london

• 1986–88 – General Manager, bolingbroke hospital & rame house, Wandsworth

our GPs. It was headed up: ‘my job is harder than yours. you have got it cushy. discuss’. and the room was absolutely jam-packed with hospital doctors and GPs having a thumping argument about who was working harder. If we had said to them ‘come to the hospital to have a discussion about commissioning’ then nobody would have turned up.”

he also wants voluntary groups, churches and faith groups and charities to contribute to cracking social

There is a place for medicine but there is also a place for a wider world view. The people entering training for public health are amongst the brightest you could hope for.

isolation. “In local government the natural view is ‘here is a problem: who is best to fix it?’”

but does he think the GPs have a valid gripe that they are overworked? “I don’t feel that it is about GPs not working hard enough: I think they are desperate to get across their message that they want to be involved in preventative work.”

If GPs feel overworked, he says, there are plenty of other people who can do health checks. “GPs need to refer people on but it doesn’t require them to do the initial check – practice nurses of course do it, but pharmacists, health care assistants, any number of people could and in fact already do – whatever works best locally.”

he is very pleased with proposals that the professional competencies of public health consultants, whether medically qualified or not, will be regulated by the health and Care Professions Council. “regulating public health professionals on a consistent basis allows standards to be set and for everyone to be stretching towards them and accountable for them.”

Selbie says that more than half of the entrants to higher professional training for public health are coming from backgrounds other than medicine. “There is a place for medicine but there is also a place for a wider world view. The people entering training for public health are amongst the brightest you could hope for.” he acknowledges that the move from the NhS saw some older public health experts either retiring or moving into commissioning, but he says some 130 of the 152 director of public health posts have been filled with the rest having substantive, permanent or interim arrangements in place.

What would Selbie consider the present-day equivalent of dr John Snow’s removal of a handle from a cholera-infected water pump in Soho, the beginnings of modern epidemiology? “local Government and the health service coming together. People will look back and say it was a revolution. The John Snow moment will be giving local government the legal duty to improve the public’s health.”

Mark Gould is a health journalist and regular contributor to The Guardian’s Society supplement.

ForESIgHT INTErvIEW


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Some of the biggest problems faced, including those in London, are because of the scale of the PFI, which the organisation and the community couldn’t afford.


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The PrIvaTe fINaNCe INITIaTIve (PfI), UNder which NhS Trusts repay private companies typically over 30 years, has been blamed for some high-profile problem cases including the demise of the South london healthcare NhS Trust (see box).

Problems with finance exist across the country and in July the National audit office published an analysis of indicators of financial sustainability in the NhS. It said that of the five NhS Trusts with the biggest deficits (four of which are in london) four were managing a PfI project. Two of the five foundation Trusts (fTs) with the biggest deficits were also managing a PfI project.

“That is not coincidence,” says Giles Peel, health adviser at daC beachcroft. “There is no question that some of the biggest problems faced, including those in london, are because of the scale of the PfI, which the organisation and the community couldn’t afford.” Seven out of the ten worst hospitals in the country in financial terms are struggling with the PfI deals, he adds.

arguably, problems with PfI were in some ways inevitable. The point of PfI was for the Government to offload the funding of capital builds for hospitals to the private sector. “but you

do not get something for nothing,” says eve Gregory, Partner in daC beachcroft’s real estate Team. “If the private sector builds them, it’s going to expect a return on that investment.”

Sharing the wealthThose managing some PfI schemes may look on with interest at discussions between Northumberland County Council and Northumbria healthcare NhS foundation Trust. If agreed, the council will take on the hospital building debt of the Trust, giving it a much lower repayment rate. The deal has been approved in principle by monitor but is still being considered by hm Treasury.

PfI has allowed the development of new facilities which have served Northumberland well over the last decade, says Jim mackey, the Trust’s Chief executive. “however, given the financial challenges facing the NhS, we must constantly look for new and innovative ways to deliver the best value for money for taxpayers. The proposed arrangement with Northumberland County Council could ultimately help save millions of pounds to be reinvested directly in patient care.”

yet, Northumbria is effectively swapping one debt for another at a better rate.

Given the constrained finances of many local authorities, the significant size of most PfI debt would far exceed any council’s appetite or ability to borrow.

another possible way out is direct help from the department of health or Government.

There are Trusts with an appetite for taking over others. a Trust that is failing – often because of its PfI debt – may be

by PFI debt?

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private finance Initiative (pfI) projects have helped private companies build more than 100 new hospitals, but are now synonymous with serious financial burden. adrian o’dowd asks how trusts can deal with the debt and what other options there are for financing.

PFI FINANCINg

PFI at a glance• under pfI projects, private companies build hospitals, with nhs trusts

repaying them typically over 30 years• The cost of capital for a typical pfI project is currently more than 8%, about

double the long-term government gilt rate of around 4%• hM treasury estimates the total commitments on current pfI contracts for

the next 25 years for the uK are approximately £200 billion

Overloaded

Health Adviser / October 2013 17DAC Beachcroft 17DAC Beachcroft

High hopes for PF2The government announced in december of last year that it planned to invest a share of the equity in a modified version of pfI (pf2) projects – its preferred model of public private partnership.

as a shareholder, the public sector would have a seat on the board of pf2 project companies and would have a stronger voice on the decisions concerning the management of the company, in theory allowing more transparent, better-value partnerships. The procurement process would have an 18-month deadline and contracts would not include soft facilities management – contracts for catering, cleaning, security and It.

Ioan davies, associate in dac beachcroft’s commercial services team, says of pf2: “some of the developments which treasury are proposing are very sensible: a beefed-up central unit that will be very strong on project management – staffed by project managers who

already have the legal, commercial and financial skills; the commitment to getting the projects delivered within 18 months; and limiting the extent of the services that are outsourced. The proposed increase in public sector equity will be an interesting challenge in practice and, crucially, whether it will makes deals any cheaper. our expectation is that the public sector stake won’t exceed more than 20% – but at whatever level it’s how that will translate across to the overall affordability of the scheme. It may also be the case that for existing pfI schemes some of the principles of pf2 might be considered when renegotiating a deal.”

There is some evidence of nervousness about pf2, says giles peel, health adviser at dac beachcroft. “If anything, we are hearing people saying, ‘why are we looking at pfI when we could potentially finance more simply by borrowing medium or long term from the department at relatively low interest rates?’”

taken over by another Trust, which receives a package of support for taking it over. but the benefits should outweigh the risks. “The whole point of fTs is that they have more autonomy and therefore the board and governors of an fT have liabilities,” Gregory points out. “When taking on an acquisition of another business, the overall business case for doing so must stack up.”

This will not be a universal solution, however, as the department is not always prepared to provide funds. “I believe there are 22 failing Trusts linked to PfI. In the

current climate, you cannot see the Government helping on all 22 occasions,” Gregory adds.

Taking a fresh lookrenegotiating PfI deals is perhaps the most obvious route to reducing the financial burden of PfI. Success is dependent on the PfI contractors being open to discussion.

hm Treasury’s code of conduct can provide a useful point of reference. The code sets out the basis on which public sector bodies and their PfI partners should

seek to improve operational efficiency and identify where savings can be made in operational PfI contracts. The code is voluntary but the department and a significant number of contractors and funders have already signed up.

monitoring how well the PfI contractor is living up to their side of the deal is important, argues Ioan davies, associate in daC beachcroft’s Commercial Services Team: “are you making the contractor do what it said it would do? are you levying deductions? are you carrying out monitoring and surveys to

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Eve GregoryIf the private sector builds, it’s going to expect a return on that investment

Jim Mackey We must

constantly look for new and

innovative ways to deliver the best

value for money

Peter Ward We need to come

up with a new structure that is inherently more

adaptable


PFI FINANCINg

see that the contractor is providing its services in line with commitments given? Poor contractor performance might be putting the Trust to cost and expense. So why not recover through proper enforcement of the deduction regime? In short, make sure that you are getting the most of the deal.”

and some fTs are looking at buying out their PfI, says Jeremy roper, Partner at daC beachcroft. These Trusts see spending some of their reserves as a better option than keeping PfI deals rolling on for another five or ten

years, although the decision depends on the value and the term left in the scheme.

reduced scope existing debt is not the only consideration. Current and future needs for capital present a dilemma. ever-increasing standards of quality following the francis report mean hospitals must invest to improve dilapidated or poor-quality premises that diminish the

than specifying the right facilities and managing them appropriately. “It’s important that what you procure is consistent with the Trust’s long-term strategy.”

John laing, already an investor in around 100 PfI projects of which about a dozen are hospital projects, is continuing to invest in PfI. Ward points to plans for a new partly PfI-funded £167 million alder hey children’s hospital in liverpool due to open in 2015.

Ward says Trusts have to adapt to changing healthcare needs and ways of delivering healthcare, so the next generation of partnership contracts must be designed with flexibility in mind. “In order to change PfI facilities and buildings, you’ve got to get approval from a number of parties that are not directly involved in developments at the frontline of the NhS. We need to come up with a new structure that is inherently more adaptable.”

Adrian O’Dowd is a medical journalist, and has worked for the BMJ and the Guardian, among others.

To discuss the issues raised in this article please contact Eve Gregory on +44(0)113 251 4872 or [email protected]

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Is

quality of care. There are hopes that Pf2, the successor to

PfI (see box), will be more efficient with a more standardised approach.

Whatever its weaknesses, some still defend PfI for its track record of delivering good quality buildings on time and within budget.

“PfI is a procurement route and it delivers,” says Peter Ward, head of healthcare Projects for John laing. “It does what it says on the tin, which is to deliver projects to a fixed standard, on time at the

agreed sum of money, and in a way that objectively delivers good quality facilities for 30 years. Prior to PfI, the record of public sector management of capital projects was mixed, and it’s easy to forget that large-scale hospital developments prior to the instigation of PfI tended to suffer significant time and cost overruns.”

Ward stresses that the procurement route used to develop a hospital is less important

The South London Healthcare caseone of the worst examples of a pfI scheme is south london healthcare, a merger of three hospital trusts. It is due to be dissolved in october and its service provision split between neighbouring trusts.

The trust was put into special administration in 2012 due to massive debts – it has a deficit of more than £1 million a week with an accumulated deficit of £207 million by the end of 2012–13. The administrators said the trust had been brought to the brink of bankruptcy by pfI deals and advised its £207 million debt be written off.

They also recommended the government pay up to £25 million extra per year to help continue pay for pfI deals at the trust, which runs three hospitals in the capital and Kent: Queen Mary’s in sidcup, the Queen elizabeth in Woolwich and the princess royal in orpington. The latter two were built using pfI funding.

The administrators calculated that the pfIs deals were costing the trust £69 million a year, around £61 million of which was due to interest alone.

In January, health secretary Jeremy hunt agreed to the trust dissolution. he said that the department would pay for the excess costs of the pfI buildings at the Queen elizabeth and princess royal hospitals and write off the accumulated debt of the trust.

Poor contractor performance might be putting a Trust to cost and expense. Why not recover through proper enforcement of the deduction regime? Make sure you are getting the most of the deal.

Under strain: Trusts weighed down with PFI debt are increasingly struggling to move forward


the dataMaking

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NhS medICal dIreCTor ProfeSSor SIr brUCe KeoGh has highlighted that providers and commissioners struggle to understand and take advantage of data on quality (see box).

“Keogh was looking, amongst other things, for board and senior management level responses to data that were highlighting poor clinical quality,” explains Giles Peel, Partner and head of the health advisory Team at daC beachcroft. “he found a very mixed picture in a large number of the 14 Trusts he reviewed, pointing to the considerable complexity and the difficulty for boards in interpreting data.”

however, data governance and protection have always been important for the NhS and the Keogh review is not a game changer, according to John Coutts, Governance adviser at the foundation Trust Network. one of the important issues to come out of the review is the need for Trusts to be proactive in investigating indications of problems, he says. “If you have an issue around being an outlier on mortality rates, for example, you really need to go into the detail to find out if you’ve actually got an issue, or if it’s a blip.”

The quality of data is fundamentally linked to the quality of health services, argues Tim Kelsey, NhS england’s National director for Patients and Information. healthcare is a high-risk business, and healthcare demand will almost certainly increase, while public sector budgets stagnate or fall. Using data more effectively will be crucial, says Kelsey, formerly the Government’s director of Transparency and open data.

ConnectedClearly, change is needed. What will the future look like? mark davies, medical director at the health and Social Care

Information Centre, suggests an integrated information landscape that can support the development of a knowledge culture based as much on maintaining health and wellbeing as providing treatment for illness. “The emerging vision is for a

unified and free-flowing data landscape, uninhibited by historical boundaries between different services and settings, with patient involvement at its core.”

further development in interoperability, (such as the ability of systems to move information around without its meaning being compromised) is needed, davies says. “The continued development of electronic versions of referral, booking, prescribing and discharges will be fundamental to realising the opportunities of modernising our systems. Standards for recording of data and data quality of our records will be as important as the data is used in different contexts between different professionals in teams, with patients and carers, and in anonymised form with those planning care.”

The current pockets of information, often in silos, need to give way to linked data sources that create a complete end-to-end picture of a patient’s journey, davies argues. “regardless of where data originates – be it from primary,

a limited capability to use data among hospital boards and leadership constrains the scope to drive improvement. greater attention will be needed to realise the benefits of health data, gill hitchcock finds.

Giles Peel GPs are an

invaluable source of the some of the

richest data in the system


Keogh’s data findings Use of data –information often used to confirm a particular viewpoint, but rarely to seek out and understand the root cause of a problem

Clinical coding accuracy – some organisations not engaging in the message the data was giving as they felt it was wrong

Driving improvements – little evidence of board and clinical leaders driving quality improvement effectively. poor articulation of improvement strategy and a disconnect between clinical leader’s perceived key issues and what was actually happening on the frontline

USINg DATA

secondary or social care – it has a valid part to play in constructing a patient’s story. as trusted custodians of patient information, GPs have a key responsibility in ensuring data is used for the immediate care of individuals. but they also have a vital role in enabling the responsible use of this data to explore the definitive needs of a population and allow for effective planning and resourcing.”

Change needs to reach the very roots of data collection, davies says: “opening up records to patients is the first step but in time we need to give patients real control.”

Patient-centredPatients themselves could take a greater role in their own care. as UK society becomes increasingly connected and tech-savvy other industries, such as finance and aviation, could offer lessons on how technology and data can increase customer satisfaction and cut costs.

To discuss any of the issues raised in this article, please contact Giles Peel on +44 (0)20 7894 6104 or [email protected] i

Kelsey agrees that getting patients to do more for themselves – perhaps by putting NhS services online – is essential for achieving efficiency savings and addressing the predicted £30 billion budget shortfall by 2020.

Comparable data could help rationalise services. Published data may also lead to improvements without any other intervention: some point to the falling cardiac surgery mortality rates after data was published.

Kelsey, co-founder of the dr foster health and social care services comparison website, has spent the last decade campaigning for greater transparency in healthcare. “It might seem far away from the realities of saving people’s lives in the frontline, but I believe that it is through the sharing and transparency of data that we will empower doctors and patients to transform the service that they all are sharing in,” he argues. his ultimate aim is to make “transparency on outcomes and the use of that data to shape improved services irreversible, fundamental and mainstream in healthcare.”

Peel concurs with this view, stressing that an understanding of data must be combined with being prepared to analyse and question. he also feels that “GPs are an invaluable source of the some of the richest data in the system.”

There are, however, obstacles to overcome. Justifying the cost of investment of analysis and technology may be hard in a time of cuts. IT systems have a poor track record and there have been worries over strict data protection legislation.

Peel points to issues at board level: “although there are very frequently in the NhS high-calibre non-executive directors from other walks of life and other sectors, a number of those find it hard to translate what is potentially very valuable experience from other sectors into the context of the NhS.”

Gill Hitchcock is a journalist specialising in healthcare, public services and technology. She writes for the Guardian, among others.

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moST PoSSIbIlITIeS for SavING oN NhS staff costs fall foul of the law of diminishing returns. Can the terms and conditions of an entire workforce be changed? In theory NhS Trusts and foundation Trusts (fTs) can terminate the contracts of staff then re-employ them on new contracts. but most boards rightly fear the potential consequences – including legal challenge, industrial action, losing staff to competitors and effects on services.

Is it feasible to negotiate with unions and staff to establish what changes are acceptable? a few have worked out concessions – in return, for example, for an agreement that there would be no compulsory redundancies within two years. others have implemented the organisational change that is necessary, promising in return for cooperation that they won’t seek to change basic terms and conditions of employment.

large-scale cost reduction by reducing terms and conditions of employment for existing staff is, however, impractical and divisive. With agreement unlikely, is there a third way? NhS Trusts and fTs are now asking for legal options for reducing the cost of employing staff. one option is employing new staff on a cut-down version of agenda for Change (afC), the national terms and conditions for NhS staff. This is perhaps the only way that

In practice

To discuss the issues raised in this article, please contact Guy Bredenkamp on +44 (0)191 404 4076 or [email protected]

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substantial sums can be saved on employment costs without unacceptable legal risk.

afC terms are not obligatory: Trusts adopted afC when it was introduced in 2004 in partnership with the unions. The seriousness of the current financial situation means that NhS employers are considering radical new approaches. Neither NhS Trusts nor fTs are required to offer afC terms to

new starters, or to current staff who are issued with new contracts on internal appointments. employers can offer any terms they see fit, including a less costly version of afC. In these circumstances, issues of contractual change and collective consultation do not arise. existing staff are not affected so the risk of disaffection and industrial action is (initially at least) low.

Potential savings1. Spot salaries: Pay progression through afC pay bands creates substantial incremental annual cost without clear benefit. New starters could be appointed on spot salaries in the appropriate band with no progression,

or on shortened bands, or with non-consolidated pay progression.

2. Reducing costly aspects of AfC: Sick pay, redundancy pay, maternity pay, unsocial hours allowances and overtime rates could all be reduced and basic hours of work increased. Temporary Injury allowance and Personal Injury allowance could be disapplied, and leaner disciplinary grievance and organisational change policies introduced.

3. Risks: There could be challenges under equal pay legislation, but this is unlikely, as the introduction of new contracts would be gender neutral. a risk could, however, emerge if medical staff – still predominately male – are excluded. age discrimination could be an issue as new starters are likely to be younger. another issue is the administrative overhead involved in operating two sets of terms and conditions side by side. This would be a very radical departure and NhS Trusts and fTs wishing to implement radically cut-down afC contracts to new starters can expect robust resistance from health unions and some impact on staff relations. Some Trusts may feel that these risks will simply have to be faced.

The scope for NHS employers to reduce staff costs by changing contracts of employment is limited. A cut-down version of Agenda for Change (AfC) for new employees could make substantial savings with low legal risk,says Guy Bredenkamp, Partner and Leader of the Employee Relations Unit at DAC Beachcroft.

Neither NHS Trusts nor Foundation Trusts are required to offer AfC terms to new starters, or to current staff who are issued with new contracts on internal appointments.


Guy Bredenkamppartner, employment & pensionsSpecialist areas employee relations, employment and pensions, equal pay, equality and discrimination, hr advisory, local government

guy is an experienced employment lawyer who specialises in advising nhs trusts, foundation trusts and national bodies in the nhs system, advising on matters ranging from complex employment tribunal claims and doctors’ disciplinary/capability issues to organisational change, national industrial action and service-wide reconfiguration.

+44 (0)191 404 4076 / [email protected]

Nigel Montgomery sector head of health partner, healthcare & clinical riskSpecialist areas clinical negligence, health and social care, nhs medical law, private clients and trusts, risk management

nigel acts on behalf of public and private sector clients in the uK and Ireland, advising on risk and claims. he has long experience of handling clinical negligence claims and particular expertise in cases involving multiple claimants. he acts for the nhs la and is relationship partner to the state claims agency (Ireland).

+44 (0)117 918 2321 / [email protected]

Eve Gregorypartner, real estateSpecialist areas health sector real estate law and education

eve leads the national dac beachcroft health estates team and has experience of a wide range of property development, planning and construction projects in the health sector, as well as estate rationalisation and management work. she advises on large and complex property transfer projects, acquisitions and disposals.

+44 (0)113 251 4872 / [email protected]

Tracey Longfieldpartner, healthcare, regulatory & public law*Specialist areas local government, safety, health and the environment(*effective 01/11/13)

tracey specialises in advising clients on a broad range of health and safety and regulatory issues. she has extensive experience of defending individuals and companies in criminal proceedings and in pace interviews, has advised clients in relation to investigations by the health and safety executive following fatalities and defended proceedings brought by other regulatory authorities.

+44 (0) 113 251 4922 / [email protected]

Corinne Slingopartner, healthcare riskSpecialist areashealthcare & regulatory law, clinical governance, regulator relationship, serious untoward Incident management, board

assurance and risk, inquests, information governance

corinne advises on healthcare and regulatory law, from patient care/consent to statutory powers and regulator relationships, particularly cQc. her work includes advocacy in inquests, judicial review, risk assessment and governance. she also assists with capacity issues, consent and ethical dilemmas.

+44 (0)117 918 2152 / [email protected]

Meet the expertsdac beachcroft is one of the largest health commercial law firms in the country, advising public and private healthcare providers and nhs commissioners. With one of the country’s most experienced and forward-thinking health advice and clinical risk teams, we offer a comprehensive, integrated legal service from a business perspective to healthcare providers and commissioners. The following are some of the partners quoted in this issue. for details of our other health specialists please visit www.dacbeachcroft.com.

Giles Peeladviser, health advisory teamSpecialist areas health advisory, healthcare and clinical risk, public sector

giles leads dac beachcroft’s health advisory team. he is a chartered secretary with a broad background in a number of fields, ranging from ftse financial services to the public sector. his particular interest is advising in governance and he has worked with numerous clients in health and the commercial sector.

+44 (0)20 7894 6104 / [email protected]

Jeremy Roperpartner, commercial servicesSpecialist areas health commercial, local government, health & social care, procurement projects, pfI and public private partnerships

Jeremy advises the private and public sectors on a range of commercial issues. These include all types of procurement , private finance Initiative (pfI) and public private partnership deals. Jeremy’s work has included pfI contracts for key worker accommodation and It schemes, as well as general eu procurement advice and non-pfI work.

+44 (0)117 918 2259 / [email protected]

© DAC Beachcroft 2013Auckland Birmingham Bristol Dublin Edinburgh Glasgow Leeds London Madrid

Manchester Mexico City Newcastle Newport Santiago Singapore Wellington Winchesterwww.dacbeachcroft.com

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