Highlights of the Week - 3rd October 2014

You can't will things to happen and I did promise only one paragraph; but by a combination of exceptional planning and luck, the Ryder Cup was won in front of me last Sunday.  The selfie has a distant glimpse of Jamie Donaldson preparing to take his final shot to the 15th green and then the pandemonium and celebration ensued following his match winning swing.  What had been a relatively deserted fairway half an hour previously was suddenly flanked by thousands of spectators and hundreds of cameramen, golfers and entourage.  It was a fantastic day - amazing atmosphere on the 1st tee over 4 hours before the start, through to the final shot and then a great night of celebrating in Edinburgh.  More memories for the Ryder Cup locker.

 

And the week then continued with the NHS promises made through the run of party conferences; some talk of more money and new initiatives and ideas.  David Cameron described the need for 7-day a week, 8-8 access to primary care.  I know that society continues to move towards an "always open" culture and that younger generations want things instantly, here and now, but I remain to be convinced that this is the most important issue that needs to be resolved over the course of the next parliament.

Investment in primary care and more professionals working in practices is definitely important - I am relentless in describing the need for us to drive change through innovative primary care providers - but I am not sure that, universally, it is about opening hours and access.  Maybe it is in London where a commuter city needs services that fit around those who need to see a GP when they are busy and away from home, but does that mean it is a policy that is fit for everywhere?  Encouraging, though, that a debate framed around primary care is central to the political discussion.  That must be right.

Highlights of the Week - 3rd October 2014 (@jeclo)

Highlights of the Week 1: GP Provider Forum-discussing how general practice could develop in the cash strapped world we live in
I think the CCG has a role to play in ensuring there is a developing primary care provider market; it is critical to the future map of services we need to see. We are not the contract holders and NHS England does also have a role in this regard, but we are a membership organisation with practices as our constituents and we are also the most significant commissioner in the health system.

The Locality held a GP provider workshop to describe to assembled practices what is happening from our perspective and to give them space to discuss together what that might mean.  There is a spectrum of practices from those who are at the forefront of thinking about how they may need to change and adapt to face new challenges to those who provide high quality services, but are overrun by the day job.

I had a comment in this blog last week about whether primary care was up to the taking advantage of the opportunities on offer; as a CCG this week we didn't respond with a "yes" to a thoughtful proposal made to us by a GP practice, prompting a tweet back "yes, but is the CCG?". It is a fair point-we have to be better at finding the intersection between what we are seeking and what primary care can offer.  We'll do better.

Highlights of the Week 2: Governing Body thinking carefully about the financial challenges and the actions we need to take to resolve
Relentless focus on recovery plans and money saving ideas is wearing and requires an ability to reenergise from time to time, lest it feels like the only purpose we have is to bear down on cost.  Money is critical and one of the biggest accountabilities we have, but it is not uplifting to the spirit and is not what drives me to work in the NHS to have a uni dimensional focus.

This week the Governing Body was reviewing our recovery actions and considering those issues that would be matters of commissioning policy or a change in protocol or procedure. It is not easy in a large group to look unified and with a single mind-that's because we are not.  Rightly, we have a range of perspectives on the set of actions we are considering and a healthy debate will get us to the best outcome.  We are under pressure though as NHS England are placing greater scrutiny both on our financial outcome, but also how we do our business and what it says about our commitment.

There are difficult choices, undoubtedly, but is was encouraging that the Governing Body was united in considering the necessity for us to take a renewed set of emergency actions and were able to debate exactly which measures would get the biggest impact, without having undesired collateral consequences.

Highlights of the Week 3: Discussions about what integration and better care funds mean for the CCG-are we ready for the changes needed?
We have been moving towards integrated commissioning and integrated provision with Plymouth City Council at some pace with an ambition about major changes by April next year; we are broadly on target for that timeline. We are also progressing discussions with Devon County Council, albeit at a different pace.

We are getting to the point now, as we consider the detail of governance and staffing, where there is an awakening to the fact that integration does fundamentally change how our CCG will work - the existence of two pooled Better Care Fund budgets totalling almost £80 million with the two local authorities does that, if nothing else.

But integration may take us further; what will it mean for the way we have designed the CCG? Does our Locality Board still do the same job?  Is it the holder of the pooled fund?  What about staffing - how is our internal business services model affected?  How is our membership role affected?  And what of the Governing Body - is there a fundamental shift to the cornerstone of our governance?

I spent some time ahead of both a Locality Board seminar next week and a Governing Body development day the week after discussing the presentation and material that we should be using to help them consider the issues and options.

In all of them, there is a "do minimum" option - the question is, "Does that help us to make the most progress, whilst balancing the risks?"

Highlights of the Week 4: Final planning for our outcomes based commissioning workshops-our strategic way forward
We are running the first of a couple of outcomes based commissioning workshops as part of our Local NHS Futures programme.  These are designed to give Executive Directors, Non-Executives, key Board members and those charged with delivering the projects within the programme an understanding of the underpinning methodologies that we have committed to as a group of senior leaders across all health and social care organisations.

There are several elements:

• Outcomes based commissioning-moving towards a set of contracts where we focus on specifying the outcomes we are after, rather than the throughputs, and leave more space for providers to innovate on pathway design
• Capitation based commissioning-moving towards contracts that acknowledge that all services are cash limited and the provider and commissioner share risk and benefit against a fixed budget also considering what fair shares of that budget would be
• Integration-we want integration to be seen as an enabling strategy too.  It is an opportunity to move towards both outcomes and capitation based contracts that bring together different elements of the care pathway in to one contract or potentially one provider.

We discussed this week the final parts of the presentation and the outcomes we are seeking.  Given our finances, we need to be hugely ambitious.  Not only is this a long term change in underpinning methodology and philosophy of contracting and collaborating, but it also needs to deliver savings in our system from next April; a massive challenge.

Highlights of the Week 5: The annual staff survey is launched and we are a lot further forward than last year
Our staff survey results last year were not the most uplifting when compared to other CCGs.  There are simple explanations - we were one of only 14 CCGs nationally who volunteered to take part in the survey, so the sample size is both small and self selecting. With over 400 staff (we have internal business services), when the smallest CCGs have less than 20, the comparison is probably less than helpful and we determined simply that we needed to do better the second time around.

It feels like we have made real progress. In areas such as the number of people receiving appraisals in the previous 12 months, we will do much better this time around; in my view, there is no reason why this number shouldn't be almost 100% and I am expecting that in the Locality where I have the most direct input.  In addition, we have introduced new strengths based appraisal paperwork so, hopefully, people will also have found appraisal a more useful experience too.

There are some interesting questions in the survey where there is a perceived wisdom about whether a low score or a high score is better.  What do you want the answer to the question "Have you ever felt under pressure to come to work when you weren't feeling well?" to be?  I completely understand that you would want the answer to be low, but I do want people to have enough sense of duty and service that they get to work whenever they can, rather than having minor excuses not to.

I wonder how many CCGs will be taking part in the survey this year. Whatever our results, I'm proud that we are one of the ones who will be and for the second year running.

You can read other blogs related to the work of the Western Locality of NEW Devon CCG

About our workplan: Western Locality Workplan

About our Locality business: Western Locality Business

Jerry Clough is Chief Operating Officer for Northern, Eastern and Western Devon Clinical Commissioning Group.  He is also Locality Managing Director for the Western Locality of the CCG covering Plymouth and the surrounding areas of South Hams and West Devon.

Previously Jerry has been a Chief Executive and Finance Director in the NHS before spending several years running his own business driving programmes of change and delivering executive coaching and team and Board development.