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Kerr Report Response


Kerr Report: Framework for service change in the NHS in Scotland

The UNISON Scotland Response October 2005

Executive Summary

UNISON Scotland welcomes the opportunity to comment on the Kerr report. UNISON is Scotland's largest trade union representing 150,000 members delivering public services. We represent the majority of the employees in the National Health Service in Scotland representing senior managers, nursing staff at all levels, Allied Health Professionals, administrative and clerical, ancillary staff, laboratory staff, technicians and paramedics. We broadly welcome Professor Kerr's report on the future of the NHS in Scotland.

UNISON agrees that the workforce is the key to NHS capacity and service re-design. It is NHS staff who will deliver the NHS of the future and therefore their representatives must have a strategic role in the implementation of any changes. Representatives should be involved at all levels during the development of the implementation plan rather than asked to comment on a finished plan. Staff are in a unique position to contribute to the plan as they view the health service from within as providers and as patients or carers. Partnership working with staff representatives needs to be embedded in structures at all levels (within the Scottish Executive Health Department through the Scottish Partnership Forum, at Regional Planning Committees, in Area Partnership Forums and Community Health Partnerships).

The NHS in Scotland has a highly trained and committed staff. There is a need to build on the well of human resource through a culture of improved leadership, collectivism, and engagement with all staff. Re-profiling the workforce requires substantial and sustained investment in education and training and is the key to unlocking capacity and to modernising models of NHS care.

UNISON is opposed to the NHSiS pursuing "partnership with independent sector providers as required" . The use of the private sector in this way will drain valuable resources from the NHS. These companies can only provide services by taking staff away from the NHS. This makes it harder for the NHS to perform, recruitment is costly and time consuming and all new staff take time to operate at their top level. The NHS has also paid to train and develop the skills of theses staff. The NHS is not able to recoup this investment if staff leave. The use of private providers also undermines the viability of the services within the NHS; there is less money available to the NHS to provide services; Staff will find it harder to develop skills if they do not get the opportunity to practice procedures regularly.

UNISON is opposed to the allocation of funding to Boards being based on performance and incentivising the allocation of resources. This is not the best way to provide for increased equitable high standards of delivery.

UNISON also opposes the use of performance related pay for senior staff within the NHSiS. Managers do not achieve targets by their own efforts alone. Success reflects the output of all those who work hard to deliver services. Rewarding only those at the top undermines the spirit of co-operation necessary to deliver services and drive forward change in the NHSiS.



UNISON Scotland welcomes the opportunity to comment on the Kerr report. UNISON is Scotland's largest trade union representing 150,000 members delivering public services. We represent the majority of the employees in the National Health Service in Scotland representing senior managers, nursing staff at all levels, Allied Health Professionals, administrative and clerical, ancillary staff, laboratory staff, technicians and paramedics. We broadly welcome the reflections of Professor Kerr on the future of the NHS in Scotland. UNISON is keen to ensure that UNISON members' experience as health care providers informs the process of change and so ensure that the NHS in Scotland is one "fit for the future".



UNISON believes that the policy of ‘Partnership' developed by Scottish Executive Health Department, the Service and Staff Side since 1997 is the key to successful implementation of the Kerr Report. This policy has a track record of success which can continue to help transform NHS Scotland over the next twenty years.

    • Embedding partnership working and empowering staff can help establish a collaborative and co-operative approach in CHP'S which will be the key to their achievement of delivery targets;

    • Partnership discussions can help transform roles and develop improvement in productivity through enhanced knowledge and skills in both acute and primary care services;

    • Health Board partnership can plan and deliver key governance and delivery systems systematically across Scotland;

    • Re-focused Regional frameworks can bring success in partnership to workforce planning and the provision of highly specialist care;

    • A strong restructured Scottish Partnership Forum can assist SEHD in achieving its key planning and delivery outcomes;

    • A new SPF can provide a first class policy sounding board for Ministers, with key representatives from SEHD Delivery Managers, key players from the Service and Staff Side collaborating to achieve the best possible standards of patient care.



"The NHS of the future will require a set of staff providing a different service, in different working environments and with different skills and roles".

This cannot be achieved by top-down dictate. It requires co-operation and collaboration between employers and staff, between staff and between employers and staff representatives. It requires a clearly agreed direction of travel. It requires employers and staff side organisations to act as pilot and co-pilot.

"It will be essential to link service planning to workforce planning at every level (local, regional, national). We need to be sure that we make the best and the most appropriate use of our staff".

Again partnership working will be the key to unlocking the capacity and potential.


Information and Communications Technology

UNISON acknowledges the need for an electronic patient, record and quantum leaps in ICT provision for case management and care co-ordination. There is partnership engagement around the E-health agenda. However, UNISON maintains that NHS Scotland is too embroiled in 'partnership' with private sector companies around key ICT Infrastructure Project.

We do not believe that this will lead to long-term effectiveness on value-for-money. Internal capacity and capability on ICT needs to be re-introduced and developed within NHS Scotland to be strategically and operationally effective in the long run.


UNISON recognises the high levels of current investment in NHS Scotland. There are however areas where value for money should be examined, in particular:

    • The economics of existing and any newly proposed PFI projects, including the quality and value for money of the provision of ‘soft fm' services.

    • The use of Private consultants by SEHD and Boards to support strategic projects. There is need to build up in-house expertise in NHS Scotland and for it to be a ‘smart' client when it comes to commissioning large projects, particularly around capital projects.



UNISON supports the concept of local care which is safe, effective and sustainable. We accept the premise that the management of long-term conditions must succeed at local level, otherwise demand on acute services will continue to increase and will never be met. There is a need to invest in primary care and to co-ordinate the management of long-term conditions:-


Multi-disciplinary Teams

There is already considerable experience and good practice here. However, there is a need for investment in staff resources and training and to manage 'single system' resources between acute/primary services in for example, occupational therapy and physiotherapy working in wards and in the community.


Integration Health & Social Care

There needs to be clear role definition, managerial and professional accountabilities. Pay and conditions of service packages need to be fair. Pay needs to be reflective of equal pay and the levels of skill and competence and freedom of practitioners to act on behalf of patients/clients.


Continuing Care of the Elderly

UNISON does not believe all hospital admission can be avoided and that the care required by vulnerable elderly is not always acute assessment and rehabilitation in District General Hospital setting. There is a requirement to plan and deliver an optimum number of continuing care NHS beds for the elderly for the provision of intermediate and end-of-life care, with appropriate medical, nursing and AHP input. NHS Scotland is a "cradle to grave service". Increasingly with demographic changes there is a need to focus on frail elderly with chronic disease(s) in terms of resource allocation.

Given the current growth in the elderly population in Scotland there is a pressing need to make geriatric nursing a rewarding and attractive career option for nursing staff.


Care co-ordination/Case Management

The ICT and systems do not exist in a systematic way across all client groups between Health Boards and Local Authorities across Scotland. ICT systems within and between NHS employers do not inter-face, nor do NHS systems with those of the 32 local authorities. The resourcing and development of universal integrated systems should be a priority. There should be a common mandatory GP ICT system based on the proprietary GPAS system.


Community Hub Resource

Collaboration through CHPs for the development of "Community Hospitals" seems an excellent proposal, particularly in relation to care of the elderly. Local resource hubs in a rural or urban setting with access to diagnostics tests and investigations; minor injury unit, perhaps allied to day care provision on a 'campus' basis with Social Work seem a crucial future networked resource to the management of the care of the growing elderly population. Such a network of resources will help stem the trickle of people with locally manageable conditions into becoming a flood into beds within District General Hospitals.


UNISON supports the four recommendations at Kerr page 28 and four associated actions. These latter four projects in our view are most likely to succeed if progressed through partnership working.



UNISON sees considerable merit in Kerr's classification of levels of Unscheduled Care and associated models of care at each level.

Levels 1 and 2 require again clear role definition, training and development in extended practice.

UNISON strongly supports initiatives to improve the valuable role performed by NHS 24 as part of the unscheduled care system and the move to a more localised support .The concept of 'Community Casualty Unit" is a good one and requires an approach that is safe and sustainable.

UNISON supports the proposal that the configuration of emergency receiving and admission at level 3 should be planned regionally.

Level 4 provision requires Scotland-wide planning and delivery.

Transport considerations are a priority consideration for patients and relatives alike.


UNISON supports the 4 recommendations on page 33 and three consequent actions.

We welcome the focus on rural communities. We have already alluded to the need to focus debate in Scottish Ambulance Service around resourcing, training and development.


UNISON supports the proposal on page 37 to create a strategic task force to examine the issue of specialisation and the impact on clinical outcomes. Any planning and delivery of models of care should be based on rigorous risk assessment and patient safety is clearly the prime factor.



The recommendation to provide care on the basis of an extended working day, with overnight care for medically stable patients is fundamental to the management and rostering of all hospital services. Its impact and pay and allowances issues which flow from it need to be carefully considered. Such developments would need to be and seen in the context of Agenda for Change, junior doctors hours, modernising medical careers. There needs to be significant partnership input around these issues.

We do not wish to create an 'out of hours' difficulty within our in-patient facilities in hospitals.



Recommendation 1(a)-(b) (p39) should be informed by partnership input at Scottish and Board levels.

The planning and delivery functions of SEHD should work closely and collaboratively with the revised and re-focused Scottish Partnership Forum.



Extended roles for members of the rural healthcare team, building on current best practice, will require sustained investment in staff training and development.

UNISON supports the development of community hospitals. We maintain, however, that there is a need to plan and maintain an optimum provision of long-stay care of the elderly in-patient beds. Such community hospitals have to be a resource centre base for in-patient and community based services. They can also act as the base for out-of-hours multi-disciplinary teams. Transport considerations must be a key planning factor in association with other agencies within NHS (NHS 24, SAS etc.) and externally.

UNISON strongly welcomes Kerr's recommendation on the development of Rural General Hospitals (RGHs) for Highland, Grampian, Borders, Dumfries, and other rural catchments areas.

UNISON supports recommendations 1-4 (p43).



UNISON supports the concept of 'streaming' elective care away from emergency care. However, the 'emergency' skills of clinical and other staff (nursing and theatre staffs) concentrating on consolidated elective specialities require to be maintained.

UNISON supports the staff of diagnostic capacity in the primary care sector. This requires to be resourced in terms of equipment and staff.

UNISON supports shared referral management systems but the systems technology skills and protocols need to be in place.

UNISON supports Recommendation 1 (page 46/7) with the proviso that there needs to be proper back up for emergency intervention on-site or from DGH sites.

UNISON supports Recommendation 2, with full partnership discussion of the implications for working hours, practices and an examination of any consequences for pay and conditions.

We support Recommendations 3 and 4.

UNISON is opposed to Recommendation 5: WE believe we should maximise the use of NHS Resources (including the Golden Jubilee Hospital, Clydebank) through greater efficiency and choice of appointments. Improved referral systems, streaming of patients, and maximisation of use of equipment and resources should negate the need for reliance on the independent sector for acute services (Diagnostics and surgical services).

Nor do we think that the independent sector is able to deliver primary intermediate and end -of-life care services to older people which is a prime NHS function.

The private sector can only perform by ‘poaching' valuable staff resources developed by NHS Scotland.

We support Recommendation 6.




Health inequalities across the population of Scotland remain significant. Contextual issues of poverty, housing, employment, transportation are obviously of great significance

UNISON supports Recommendations 1: 3 (page 48). We need particularly on recommendation 2 to invest in District; Community Nurse and Health Visiting resources to enhance front-line services in the community.



The Regional Planning Groups, which are given a new emphasis in Kerr's recommendations, should be developed as 'partnership' groups and work in accordance with partnership principles in relation to service and workforce planning.

Similarly CHPs need to have effective partnership arrangements to best deliver their key objectives. UNISON would caution CHPs taking on financial delegation from NHS Boards. The impact of CHPs becoming fully responsible for financing all services from delegates' budget fundamentally alters the funding and financial accountability arrangements in NHS Scotland.

UNISON would oppose the use of financial incentives to 'reward' performance of NHS System. The experience of competitive 'trusts' and the NHS in England & Wales shows that this is not the best way to drive up overall equality and standards of care.

UNISON would oppose performance related bonuses for Clinical and Managerial staff. The provision of NHS services is a team effort delivered collectively.

Planning mechanisms at Recommendation 1 should be partnership bodies. UNISON supports Recommendations 2-4(page 52). In Recommendation 5, CHPs should develop effective partnership arrangements. UNISON would oppose Recommendation 6 as counter-productive to enhancing overall performance and quality in NHS Scotland.



UNISON supports the KERR recommended actions on p54/55. Our 58,000 members in Scotland and their families are users of NHS services and deserve a voice as 'consumer' interests. UNISON believes that directly elected Health Boards would strengthen the public and patient voice. We therefore support the Direct Elections to NHS Boards (Scotland) Bill being promoted by Bill Butler MSP.




UNISON recognises that CHPs present a fresh opportunity for inter-agency co-operation. We repeat that delivery of key CHP objectives can be best achieved through building the CHP structure on the foundations of the 'partnership' principles and policy central to the way of working in NHS Scotland. UNISON supports the Recommendations at 1 and 2 (page 57).

UNISON supports the development of a common ICT system compatible with other agencies. Such an ambitious project is best advanced in the same 'partnership' manner as other strategic developments around Shared Services, Logistics and Procurement. The project requires to be underpinned by the Organisational Change Policy.

UNISON supports Recommendations 1-3(page 59). The target in Recommendation 2 is ambitious.



Partnership Working is the key to empowering front-line staff. National Strategies for service change should be informed by debate in the renewed and refocused Scottish Partnership Forum and delivery will be assisted by the reform of SEHD structures. Strong and effective leadership is required.

Develop its staff and NHS Scotland will develop its services and enhance quality. The wealth of knowledge, skills and experience of all NHS staff should contribute to change and innovation. Best practice needs to be systematic.

UNISON welcomes the suggestion of an in-house capacity to develop change, rather than reliance on expensive external consultants.

Collaboration with the academic community and other countries should inform strategic thinking on service re-design and development.

UNISON supports Recommendation 1-3 (page 61)



UNISON supports Recommendations 1-4 (page 62). Standards can only be raised by improvements, not only in clinical governance, but also Staff Governance considerations.




The challenge of change can only in our view be achieved through mature partnership working with staff side organisations in NHS Scotland at all levels.

If ICT is the 'glue' to integration of NHS care co-ordination then partnership working is the strong enabling force which will drive and support:-

    • service re-design

    • role re-design

    • increased capacity and skill

    • better delivery.

This can be achieved within an employee relations environment which is stable, positive, constructive and forward-looking.


For Further Information Please Contact:

Matt Smith, Scottish Secretary

UNISON Scotland


14, West Campbell Street,


G2 6RX

Tel: 0870 7777006

Fax: 0141 342 2835

e-mail: matt.smith@unison.co.uk