Highlights of the Week - 14th November 2014

There is nothing as simple as taking turns; something we teach children from a very early age is the importance of everyone getting a chance and giving each person an opportunity by going one at a time.  However, I was struck again this week about the profound impact that a tiny bit of enforced turn taking can have on a group of highly developed, intelligent, genuine and caring people.

I have mentioned several times the use we make of Nancy Kline's Thinking Environment - a set of 10 principles that can create a space in which people can do their very best thinking, in order that they will then individually and collectively come up with their highest quality decisions and actions.  The principles are not in themselves complicated, but they do require practice.  For example, setting a rule that it is important to pay attention to the person who is speaking without interruptions is about as simple as it could get, but how many times are you really paying full attention in meetings, listening and seeking to understand the point of view of the speaker?  And how often are you waiting to jump in with the point that you have already formed?

The Thinking Environment has a set of conditions for effective meetings and one of those is "thinking rounds" the notion that the group is set a clear question to consider and then each person in turn, without interruption and with everyone else attentive, gives their perspective - or in other words, we take turns.  Everyone gets a voice (you don't have to talk, you can simply pass on your turn if you have nothing to add) and there is no battle for space.  In particular, there is no domination by louder individuals and there is a calm balance to the meeting.

We had a workshop this week to think about how integration may impact on the structure and operation of the CCG.  Everyone in the Governing Body is interested in the discussion, particularly me, I have a lot invested in our work in Plymouth, but there is a danger that 2 or 3 of us, usual suspects, will overpower.  Instead, with a bit of simple facilitation, we heard from everyone and had a much higher quality discussion as a result.

Sometimes the most profound ideas are simple and things we already know.

Highlights of the Week - 14th November 2014 (@jeclo)

Highlights of the Week 1: We're at Plympton Library - it is exactly where we need to be and perfect for our needs
Every penny counts and more importantly everyone in the organisation having a role to play in financial recovery and feeling involved is vital.  So counting the savings around venue costs, hospitality and other running costs is great attention for the business management and admin teams and we are making real progress.

So we found ourselves in a meeting at Plympton Library this week- a room big enough for our needs and a whole lot cheaper than a hotel booking.  We can't solve our financial problems on running costs (we are already over £2 million under our target), but another £500 in the right direction helps.  And there is something about being in our community, sharing the 2 minute silence with other library users, that helps to ground and remind about what we are here to achieve.

Highlights of the Week 2: Integration discussion @NEWDevonCCG Governing Body-it's happening everywhere, how do we live with different speeds?
Fantastic news this week as the Cabinet of Plymouth City Council passed a set of resolutions marking the next phase of agreement about how we intend to work together on integration.

We cover Devon and Plymouth local authorities and if we move towards integrated commissioning in one part of our CCG then it will impact on how the whole organisation runs.  We spent some time this week with the Governing Body exploring how we can move at different paces and, indeed, have different solutions within the same strategic intent; in short how do we promote integrated commissioning with Plymouth whilst working in a different way with Devon County Council.

Clearly it is not straightforward as we need to be consistent for our staff.  But if you start with the purpose - we are doing this because we are clear that integrating commissioning is a key element of driving forward the integration of service delivery and that in turn is about providing better and more joined up services - in fact the integration of commissioning only makes sense to the extent that it impacts on individuals - then it is an issue we need to resolve positively, rather than a barrier.

So we were finding ways to make this work and hopefully that leads us to a successful resolution in December about our next steps.

Highlights of the Week 3: We are taking some really challenging decisions; but hurrying slowly and making sure we get it right
Another week on and more consideration of the range of options that we are considering to help improve the financial position that we are facing.  I have been in turnaround situations before and it is easy to race to a set op decisions in the heat of the moment and then live with the implications later.

We are trying to take a measured and evidence-based view and the more we discuss what this might mean, the more people are having open discussions about whether many of the treatments we pay for and carry out really add value.  The process we are using, based on a marginal analysis approach used by Professor Cam Donaldson, gives us a rigour to the method and ensures we aren't caught in the pressure of the moment.

I have been impressed by how our clinicians have responded to the challenge - it isn't easy for those in the CCG as they represent a far wider membership who will deal with the impact on any decisions in more complex conversations in consulting rooms over the following months or years - but they recognise that not everything we do is equally valuable.

Highlights of the Week 4: IATC2 - more people in the room from outside the CCG; great to be spreading the learning
I ran a session this week to describe our Individuals at the Centre approach to a new group - setting out the importance of living the statements that you write on the wall on in documents - for us a vision that is "Healthy people living health lives in healthy communities" and a way of working by putting "Individuals at the centre"; in summary either "be it, change it or take it down".  In other words, don't have appealing strap lines that you have no intention or ability to deliver - understand what you are doing to get there or change what you say.

The great thing in the session this week (we have now got to over 75% of our staff in the CCG with an initial half day workshop over the last 18 months) was that there were more people from outside the CCG than our own staff.  We have attracted a team from South Devon and Torbay CCG which is great and within the partnership approach to the projects in the second year of the programme, we had colleagues from one of our local mental health providers, from a care home provider and from Plymouth City Council.

It is encouraging, not only that those people were there and interested, but that our staff when given the opportunity to think about projects for themselves naturally choose to look for a range of partners to deliver - integration has a macro and a micro face.


Highlights of the Week 5: A non searchable YouTube video, but delighted with the online support to our programme http://youtu.be/10Z6yVrc-K8

Have a look here IATC2, Module 1
We need to find increasingly efficient ways of engaging staff and in turning the second year of the IATC programme to an ambition of 15 teams we need options that don't rely on face-to-face contact that would impact on other business delivery.

So online messages are part of the answer.  We expect two change agents in each team to spread the message, but they are supported by online material with the content of the sessions, "nudges" that we send out every Friday reminding all the team of key headlines and then a few short videos that summarise key ideas from the programme, from either Tim Robson (from nowshowup.com who is co-running the programme) or me.

They aren't private, so appear on YouTube as the easiest way to share them, but are non-searchable as they are not primarily intended for a wide audience.  I think this one is really good and will support the teams as they work.


It will certainly encourage them to do some high quality thinking first, before they rush to action - Thinking Environment via a nudge?

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.

Highlights of the Week - 7th November 2014

I finished the week talking about "CLANG" - winning ways to mental health and wellbeing - as a result of being given a pen with one of those pull out information sheets cleverly contained with in it.

It lists the five actions that we could all take to improve our mental wellbeing and in that respect I suppose it sits alongside advice about diet, exercise, smoking and alcohol that impact on our physical health.

CLANG stands for:

Connect - link up with people around you

Learn - explore something new

Active - discover an activity you enjoy

Notice - be curious about the world you live in

Give - share something with others

It was a really useful reminder for me, served up in a pen format, of the importance of working to maintain mental wellness in the same way that I pay attention to maintaining physical fitness.  My mother suffered from mental health problems since before I was born up until she died.  Experiencing that as a child, young adult and then as her next of kin left me with a profound sense of the importance of understanding that my mental wellness is not something to be taken for granted.

And talking about that and sharing experience is part of how I stay well - alongside running and other physical activity.  I have recently given up alcohol for (an intended) 6 months.  I know the next 6 months will be pressured and stressful at work and that relying on a glass of wine or two or more at the end of the day will be hugely counterproductive.  So I'll run and walk the dog instead, but most importantly, looking forward at the prospect, rather than waiting until I am deep in the mire, is crucial.

Of course giving up alcohol is also about weight and physical fitness, but I don't think there is a necessity to draw a line between the two as both are important.  Good behaviours in diet, exercise and alcohol will have dual benefits.

6 weeks in and I feel good; a few pounds lighter and clear on work priorities, ready for another week.

Highlights of the Week - 7th November 2014 (@jeclo)

Highlights of the Week 1: @NEWDevonCCG Governing Body in Barnstaple and focussed on the key issues we face

It is not a short drive to Barnstaple from where I live in South West Devon, but we are a big CCG and if the Governing Body is going to meet in different parts of its patch, there will be some travelling to be done.  I loaded up three passengers (the CCG cost saving drive is alive and well) and set off. It does feel important that we do remember the diverse communities that we are responsible for and moving the Governing Body meeting around is part of that.  

It was a long meeting - that can't possibly be a highlight - but given the importance of our financial recovery plan and the actions that the Governing Body needs to be aware of or approve, it was necessarily covering a lot of ground both in the public and private sections.

And just to add to the sense of the importance of our discussions, we heard part way through about the question Ben Bradshaw asked David Cameron at Prime Minister's questions about our financial challenge and actions proposed.

But it did feel like we were doing what needed to be done and, however complex and challenging, the Governing Body discussed, debated and agreed a set of measures to improve our year end position.  So not a highlight in terms of length or the activity, but was purposeful and important.

Highlights of the Week 2: Meeting with @SteveWaite_PCH from @PlymouthHealth - exciting times and lots of energy for the path ahead

We don't manage to catch up as often as I would like, but it was good to sit down with Steve Waite, Chief Executive at Plymouth Community Healthcare CIC this week and talk about the range of issues that we are both working on.  Keeping a senior dialogue is clearly important; often it is the unwritten tone behind emails that is helpful or the briefing on connected issues that will make the difference.

Plymouth Community Healthcare CIC have just been announced as our preferred provider for community services in Plymouth and South Hams & West Devon and their work on the integration of services with the local authority in Plymouth is a key component of our strategy.

No earth shattering decisions, no deals of any magnitude, but a clarity on our joint expectations that will help to guide future discussions.

Highlights of the Week 3: A copy of Strengths Focused Leadership arrives - a book with lots of ideas and a clear philosophy

Kathy Toogood and Mike Roarty's new book Strengths Focused Leadership arrived in the post this week and it looks fantastic.  I have read a draft copy as the work we have done in the Western Locality of the CCG with Strengths over the last 18 months forms a short case study, so I know that the content is great, but it is always good when the cover looks enticing.

I am a complete convert to strengths focussed leadership and couldn't recommend it highly enough.  It isn't about pretending all the world is rosy, but in solving the problems we have, isn't it better to try and use the strengths we have, rather than worrying about the skills we lack or the things we are weaker at?

I'm no salesman, but if you ever fancy an understanding of Strengths with a clear account of how to implement in day-to-day practice, you could follow the link.....Amazon - Strengths Focussed Leadership

Highlights of the Week 4:  Catching up with @JanSobieraj about all things leadership and the state of the NHS

I have met Jan fleetingly a couple of times over the years in our roles in Yorkshire, but I have never sat down face-to-face and chewed the cud about the state of the NHS and Leadership.  So Jan's trip to the South West this week were an opportunity to share views of the NHS from very different perspectives.

It was really enjoyable to hear about Jan's work on Leadership at the NHS Leadership Academy - we explored how their work impacts at a CCG level on a day-to-day basis, equally Jan was keen to hear my perspective on how working in a CCG feels and the bits of NHS policy that help or hinder our work.

We both recognised some of the shortfalls in system design and how we are working to overcome different issues.  Although we are in very different roles, it was encouraging that are perspectives and indeed some of our ideas about solutions were not a million miles apart.

Highlights of the Week 5: Plymouth Health and Wellbeing Board Solution Shop on mental health.  Feels like a positive H&WB mode

The Health and Wellbeing Board in Plymouth should really be pleased with some of the processes and mechanisms that it has put in place to discharge its responsibility.  It has a much wider membership than most with only a few local councillors and an overwhelming majority of partners and stakeholders.  Other than meeting formally in the Council building, it couldn't do much to feel less like a  Council Committee.  

Solution shops are another defining feature - Health and Wellbeing Board members meeting with a range of interested people and groups around a particular issue with the disucssion led by non Board members.  This week's discussion was on mental health and was interesting and valuable.  I found myself discussing how (fictitious) Bob might experience issues in his life within Plymouth and when he would need support from an informal network and when from statutory services.

The discussions were engaged and drew on the experiences of users and particularly those who work in charities and community organisations supporting people with mental health issues.  We did spend some time talking about the importance of talking about mental wellness as well as mental health issues.  

We recognised that improvements would be because of a range of actions and that NHS services alone were not the answer, but when needed, they do need to be responsive and of the right quality.

  

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.

Highlights of the Week - 31st October 2014

An undeniably interesting week and one in which our local issues got more of a national and press airing.  We have made a lot of our financial issues directly public this week as a result of informing stakeholders about the "urgent and necessary measures" we need to put in place in order to attempt to hit our financial plan.  This shows a need to find around £14 million of additional savings by the year end - a huge number, even if the turnover for those months will be around £500 million.

The measures include providing a new elective pathway for people with a BMI of over 35 who would previously have had surgery as a usual treatment for their orthopaedic condition; we are now looking to ensure that they are offered weight management initially in order that they benefit more from the surgery or, as is already the case for some, opt to have no surgery as once they have lost weight, their pain reduces and mobility improves.  Elective orthopaedic surgery for people with BMI of over 35 provides limited benefits for some, there are risks and our proposals are in line with NICE guidance, but that doesn't stop the idea raising concerns and comments.  We are also looking for people to have given up smoking for 6 weeks prior to surgery in order to improve their outcomes.

Within the expected local debate we now know that our financial challenge is big enough to recieve national attention and so Simon Stevens was asked a question about our proposals at the Health Select Committee at the start of the week.  He expressed some reservation and the media interest continued. And then, of course, it got a mention in Roy Lilley's blog.

Which all adds pressure to those who are trying to find the right solutions to a huge challenge for which there are no easy answers. It is not the most uplifting of tasks to be sorting through a list of ideas to determine which ones are acceptable and which aren't, but it is necessary that somebody does.  Our Turnaround Director will start next week - a sign of the next phase in escalation and hope that gives us some further support, but we can expect more detailed scrutiny and challenge ahead.

Highlights of the Week - 31st October 2014 (@jeclo)

Highlights of the Week 1: Locality Board is focussed on understanding issues and making decisions on commissioning, finance and integration
We are working to ensure that whilst we are in financial recovery we are clear about how to be most efficient in our "business as usual" processes.  This includes being clear about the role of the Locality Board and whether it needs to meet monthly or perhaps slightly less frequently.

This month, though, showed the importance of the clinical leadership that it provides within the Locality.  There was a hugely engaged discussion on financial recovery and the measures we will need to take over the next few months. Members rightly questioned from a clinical and quality perspective, but were supportive of the proposals.

We were reviewing a key set of actions around a key commissioning decision and the Board were clear about the prinicples and management actions suggested as well as supporting the conclusions that they were presented with.

And they are clear about the imperatives of integration; we have an opportunity in Plymouth to create something that will have lasting impact and they are prepared to think through how things would need to change in terms of their own role in order to deliver those benefits.

All in all, it felt like clinical leadership in action with some key issues to address.

Highlights of the Week 2: Individuals at the Centre 2 launches: 16 teams with ambition to improve the way we work of key projects
It was great to be back at the start of our Indiviudals tat the Centre programme for the first module of the 2014/15 programme that will run through to June next year.

We have scaled up this year with 16 teams compared to 5 last year, so our ambition is huge.  The teams are represented at each for the four modules by 2 change agents who then are responsbile for taking the ideas back in to their project teams and inspiring progress over the weeks between the modules.

So the programme takes 16 project outlines and looks to support their development and delivery by exposing them to some developmental thinking around the purpose of their work and their ambition.

Fantastic success last year, so looking for many more exciting stories to tell this year.

Highlights of the Week 3: Money is central to IATC2; but we can have the discussion and ensure focus without losing the impact of all that we are trying to achieve
And clearly this year the context for the programme is difference.  At a time when we have targeted a further £750,000 of savings from our running costs (on top of our projected underspend of £2 million) we need to be clear about the value that any time away from the core financial recovery work gives.

So we spent a good proportion of the day thinking through how each project will impact on the financial position of the CCG. It was heartening that all our staff were very much energised by that discssion and, far from being the moment that killed all the optimism, it was the point at which the projects becaame real and their delivery even more important.

Highlights of the Week 4: Integration seminar looks at the impact on Devon of our proposals in Plymouth. One CCG with two local authorities
Integration makes yet another appearance in the blog and, as most will know, we are making fantastic progress with our work in partnership with Plymouth City Council with a dual ambition about integration of both delivery and commissioning by March 2015. 

In an organisation like ours where under a third of our population is covered by the footprint of the City Council, this does beg the question, "What about everyone else?" and in our context, what about all those people who are covered by Devon County Council.

At one level, the decisions taken in one area are discrete and there is no real need for the Local Authorities to have an overly close working relationship, but, for us, the decsion in any part of our organisation has an impact elsewhere.

For example, we will struggle to have a governance and decision making structure in one part of our organisation that is different from the rest, so there is a constitutional issue if we alter how the Locality is governed to move towards a Joint Strategic Commissioniong Board.  Equally, if we link a proportion of staff to a new commissioning unit in Plymouth, there is an impact on our internal business support services that impacts large parts of the CCG.

This workshop gave those learders from across the CCG a chance to look at the issues and think through the implications.  Some of us have been exposed to this each and every day for the last year, but clearly people outside of Plymouth haven't.  Getting everyone to the same level of understanding is important as we are nearing another key deicsion point and we need to ensure due dilliegnece.  The session pointed to the challenges, but gave us the clear sense of the questions we need to answer over the next few weeks, so hoepfully we arrive at the next Governing Body meeting with a clear recommendation.
 
Highlights of the Week 5: Professor Clough on Woman's Hour http://bbc.in/1p9AOHk Dementia and cinema - fantastic!
Not often that my father's work and mine overlap, despite the fact that he has been a social work academic at Bristol and Lancaster Universities for most of his career. We share plenty of similar stories, but not many direct connections.  His last piece of work with Age Concern in Lancaster before he finally retires (well, we will wait and see as he is still very much active in his early seventies) has been about dementia and isolation and one of the projects they have been experimenting with is about creating dementia friendly screenings at a local cinimea designed for couples and families to attend.

They have been very successful and have attracted the interest of Woman's Hour and so the 11 minutes of this episode explore the project.  At a time when the press is full of stories about the issues of social isolation, this feels very uplifting and optimistic.  I'm a dementia friend and so keen to explore these types of initiative and very pleased to listen to these wise words!

 

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.

Highlights of the Week - 24th October 2014

The NHS has been in the spotlight all week; the run up to the announcement of the 5 Year Forward View, the fanfare of the launch and then the analysis, political comment and media dissection of its content.

I can't remember anything that has been received with quite such a collective, positive reaction since probably the NHS plan over a decade ago.  And in my very brief reading it should do - it makes sense and it seems to place priority on the areas of the system that need attention. It also suggests some models of integrated systems that point towards an intention to be radical and allow innovation that is locally shaped and influenced.

The timing is interesting and deliberately plays in to the creation of political manifestos for the next election to test the extent to which parties want to be seen to align with the plan as laid out.  And, whilst that is part of the test, the real success will be be driven by how a new political party will go about implementing the challenges described - will they see the messages about one size not fitting everywhere and allow variation or will a new Secretary of State worry about the distance that NHS England creates between the political direction and implementation, let alone allowing further decentralisation?

I am concerned about the money too.  I celebrate the fact that we have acknowledged that the whole of the £30bn Nicholson challenge cannot be resolved by efficiency alone, but we have still accepted a position that requires ongoing levels of efficiency on a year-on-year basis that have never been delivered in the NHS.  The financial challenge feels huge at the moment and to be hitting across very many diverse geographies and systems.  I can't quite see how the promise of £8bn over future years will come soon enough to stabilise the NHS and allow it to further innovate and change.  It also moves us from a £30bn challenge  to a system that can deliver £22bn of savings.

But definitely a week for celebrating a view of the NHS that is both inspiring and optimistic; something worth keeping working to secure!

Highlights of the Week - 24th October 2014 (@jeclo)

Highlights of the Week 1: Urgent Financial Measures are not all negative; we can create some permission to do things differently too
How do you take a very busy and stressed organisation and create capacity to place an even greater focus on something? It is an age old question, because the perceived wisdom is (and I would agree with the intent) that you need to reduce the number of priorities and let some lower importance issues be suspended for a while. In our case we need more staff working on financial recovery this year, but we struggle to see how  the "business as usual" consumes any less time and energy.

We list of things that we "must" do seems powerful - winter resilience, referral to treatment time delivery, immediate capacity and activity pressures in urgent care, integration with local authorities, our transforming community services procurement which is at a critical stage and the beginning of 2015/16 planning.

We did come up with some ideas this week about how to improve our efficiency and have adopted a set of measures that questions the need for all the meetings we create and looks to cancel, shorten, reduce attendance and encourage deputisation.  It isn't as easy to do as to say, but there are some signs that it will provoke some more radical thinking in the CCG.

Highlights of the Week 2: Staff do understand the pressures and are keen to help: staff briefing is standing room only this week
The staff briefing this week was almost entirely turned over to discussing the financial pressures we are facing and the actions we need to take to attempt to improve our position; certainly not the most anticipated task of the week to deliver the message (again) and to explain what it will mean for individuals and the collective staff group.

The reality is that we can't solve our overspend on a £1.1 billion budget by addressing our running costs of c£20 million alone, but we do need to continue to look for efficiencies in the way that we run the CCG. We are already predicting a £2 million underspend on running costs, but are looking in our latest set of measures for an additional £750,000 saving through to the end of the year.

Most people know the kind of measures this means - extending vacancy control processes, looking for savings on travel, legal costs, training budgets, venue hire and hospitality - and to their credit, there is only support from the staff in the room. 

People are certainly interested and understand the importance; it was the largest attendance we have had at our Windsor House office for staff briefing, which is usually pretty well attended in any case. Optimistic that this is one part of our additional measures that will deliver.

Highlights of the Week 3:NHS Futures Strategy Project;making based use of integration and outcomes & capitation based commissioning
The Strategy Project within the Local NHS Futures Programme met for the first time this week. It is the project (one of nine within the programme) that I'm the Senior Responsible Officer for and keen to ensure that it works well to support the delivery of the key areas of change.

The role of this project is to examine the strategic approaches that are new, innovative or simply haven't been utilised to their full potential in Devon that will help to shape a sustainable system for the future.  We are looking at outcomes based commissioning, capitation funded systems (including accountable care organisations), integration, lead provider models an Public Health approaches to resource utilisation and prioritisation.

There was a good sense of energy in the meeting with a clear understanding that we need to quickly provide ideas and approaches for delivery projects to start using - in reality we need to understand rapidly the extent to which Local NHS Futures will drive next year's commissioning intentions partially or fully, as we are at the point of the year when that is becoming real. A mood of cautious optimism...

Highlights of the Week 4: Integrated Health and Wellbeing Board preparing for @NEWDevonCCG Governing Body & @plymouthcc Cabinet Key decision
It is a recurring theme; the work we are doing with Plymouth City Council to integrate commissioning and delivery of health and social care services does seem to appear in my highlights each and every week.  And probably that is right!

We reflected on the size of ambition this week - fully integrated provision of health and social care with all staff employed in a single organisation by next April and all health and social care commissioning spend in one integrated pool with a single management team by the same time. That is a massive challenge, but we are making fantastic process.  This week we seem to have moved forward considerably with the financial and governance discussions, which was really heartening.

There are crucial checkpoints ahead; we have a paper on the next steps and approval for some of the governance infrastructure to take to both the Cabinet of Plymouth City Council and the Locality Board and Governing Body of the CCG in November and early December.  We were reviewing those papers this week and there was good agreement and sign off. Plenty more work to do before we submit the final version, but amazing progress and definitely a real highlight.

Highlights of the Week 5: Head of Nursing and Quality Interviews-"Given your challenges, why would I want to come and work for this CCG?"
We interviewed for the posts of Head of Nursing and Quality on Friday.  There is always that part in interviews where the candidates have an opportunity to ask the panel any questions they might have and we had explained very clearly to the candidates at the start of the day that the process was as much about them deciding whether they wanted to choose us as us considering whether we wanted to recruit them. The question "Given your challenges, why would I want to come and work for this CCG" was certainly to the point and caused some reflection.

We are in a very difficult financial position, we are under intense scrutiny and we have some significant performance challenges.  Some relationships are incredibly positive, but we have some hugely challenging negotiations too. We had Greg Dix as the external assessor, Director of Nursing at Plymouth Hospitals NHS Trust so we reflected a bit on why work in the system as well as the CCG in particular.

And the reality for those of us on the panel was because it matters, because difficult and intractable problems are more interesting and stimulating than the routine or mundane and because there is a hint of optimism that out of the crucible of the intense problems we are facing, we can create something that does provide some solutions.  

Not at any cost - there is a balance between challenge and unacceptable stress, but there is a reason to keep working to sort issues, even when the odds seem stacked against us.


Perhaps now, with some new ideas and inspiration from a five year forward view, there is even more reason to work here.

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.

Highlights of the Week - 17th October 2014

Another busy week.....

I used to coach for a large part of my job; perhaps 6 or 7 sessions a week with different managers, executives and clinicians.  A large part of those discussion would be the presentation of stress, the times when multiple factors hit our lives at the same time - problems at home, problems with a relationship, moving house, money, health and different situations at work.

It is not usually just one element as, often, we can cope with one part of our world being out of alignment with the balance of other bits that are working well.  People would invariably feel unable to cope when a myriad of different issues were hitting them at once.

At the moment work is really challenging: three and a half days last week were spent in meetings that were entirely about the financial position and for the others it was the context; family life is hectic (and it will feel more like that as I spend a bit more time both physically and mentally at work) and we are in the middle of some internal building work at home. That means that the house is in chaos with dust and material everywhere, but there is also a project plan and we need to maintain our part of the schedule to ensure we can move out of and in to the right rooms at the right time. Sleep is more fitful.

So the brain is full - when to sand the floorboards, when to fill the cracks, the best order to decorate and where things will be stored.  Physically tiring too - home from a long day and then spend three hours on hands and knees sanding.

The antidote is not easy, but running is important for me (not as easy with dark mornings, or certainly not as inviting) and interesting that Simon Stevens has highlihgted the issue of workforce fitness again this week, though I'm not sure joining gyms is the real answer.  The truth is that we all need to recognise the challenges we face across all aspects of our life and, as the pressure increases, be clear that we are taking steps to manage that impact.  It isn't ok for me to shout at the kids, kick the dog or find release in a bottle of wine each night; now is the time to be aware of self first of all and of others around me.

Highlights of the Week - 17th October 2014 (@jeclo)

Highlights of the Week 1: A week of true challenges but the team in @NHSNEWDevonWest has come through with flying colours
Given that I've spent three days in all-day financial recovery mode, I haven't been around much in the Locality to explain, motivate and encourage the level of effort that has been required to produce the recovery plans, action and evidence that give assurance about our forecasts.

But, as usual, the team in the Locality has responded to some fairly short and blunt requests with a collective response that has been really impressive and of great quality.  They work smoothly and efficiently under pressure; no panic, just a complex and time consuming task completed speedily and relying on each person to produce an element of the jigsaw.

There is a great balance in the team, but together they invariably produce when we need them to most.

Highlights of the Week 2: A late Friday meeting with @PlymLeader sharing perspectives on the importance of integration and our joint perspective
Mostly after a difficult week I could do without a 5pm meeting on a Friday.  But this week, meeting with Tudor Evans, Tracey Lee and Carole Burgoyne at Plymouth City Council to talk about our integration plans and joint work was a positive way to finish.

The financial challenge in the CCG causes ripples across our partners - they clearly want to know how our budget position will affect the plans we have to work more closely together and also how the CCG will protect resource allocation in the city at a time when recovery is the number one priority. 

We agree that we need to keep our integration momentum, especially when budgets are hugely pressured - we can both point to savings we have made this year as a result of our joint work. Even more importantly, we are clear about the benefits that a pooled commissioning fund will bring from next year.

Highlights of the Week 3: A meeting with Monitor about our community services commissioning strategy.  Interesting perspectives to explore!
There is a lot discussed about Monitor and their approach to competition and integration and this week we got to sit and discuss our plans for community services with a team from Monitor who came to visit.

We clearly have very different roles and therefore our perspectives are hugely different, but I didn't find them difficult, uncaring or obstructive, just with a very clear sense of their purpose and the job they have been given to do.

Our plans for community services describe approaches that would see an open competitive procurement for some services, such as urgent care, with a more restricted procurement process for services for complex adults, recognising the importance in this area of integrated pathways.

There was a lot for both of us to reflect on and there is still further clarity required on exactly how the final proposals will be received, but it felt like we had made real progress and we have a good sense of how we need to proceed.

Highlights of the Week 4: @NEWDevonWest Leadership Team day looking at integration and financial recovery: great focus on both
In the middle of the intense work on financial recovery, it was important this week to raise our heads from the immediate work to check that we are clear about what we as a team in the Western Locality are trying to achieve for the remainder of the year and that it fits with our slightly longer term ambitions.

Integration will have a big impact on the team and the staff within the CCG.  We don't have the final staffing model for an integrated commissioning organisation yet and we may have some time when we work in a virtual or seconded team administering a pooled fund, but we do have a clear intention and direction that will see big changes to structure and ways of working.

We were very clear that the work was critical to our future success and we can only see the increasing importance as life looks tougher.  The Leadership Team got a good grip on both the integration issues and on the financial challenges, where we worked in some detail on the next steps and actions.

Highlights of the Week 5: End the week at the Great West Run - there are different types of tiredness, but this is one that sustains
Very little training (enough running on the moors, but nothing that could be classed as sufficient or relevant to running a road half marathon), but I knew I'd be ok to get round and enjoy the feeling of running with a large group of people.

And, however slow, however hilly and however painful at times, it was a beautiful sunny autumn morning and I did spend the rest of the day with the wonderful buzz that a long-run can bring.

(even if I was back to sanding by the evening!)

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.

Highlights of the Week - 10th October 2014

With the ongoing announcements at party conferences, I've been reflecting on the extent to which we manage to get parity of esteem in mental health.  Before criticising anyone else or the system we operate in, I have been working in and around the health service for over 20 years with various roles of influence in resource allocation and the commissioning and provision of mental health services, so the reflection is personal too. But we just haven't got anywhere near parity between general health and mental health services and that doesn't seem to be getting any better, despite political promises of future investment or the release of monies of psychiatric liaison or crisis services.  Ultimately, I do think a large proportion of that blame is political, rather than in the delivery.

It has been going on for years; Mental Health wasn't the most heavily invested national service framework, we didn't create and drive the improvement of mental health services in the target driven culture of the NHS plan with anywhere near the ferocity and determination that we did with general services; we don't have the same measures for referral to treatment times nor the datasets that are recorded routinely elsewhere; we don't have the political attention when we fail to hit a mental health target as we do for A&E or finance or elective waiting times; the Better Care Fund had a prime opportunity to focus itself on mental health a real candidate for joint, integrated improvement, but is really interested in a 3.5% reduction in emergency, acute hospital activity; and not once in the whole of the discussions about the resilience of our system over the winter months has mental health been a central part of a discussion.

It would unearth a major issue of course (a financial bill that we simply couldn't afford locally) if we did apply the same targets and record the same information; there is a good reason not to. I don't think though that, at its heart, it is a particularly difficult challenge, to achieve parity; every time we set a target, aspiration or ambition, we could ensure that it applies equally to all settings. If we can't do it quickly (we don't have the money we had in the NHS Plan to make rapid progress) we could start and set a long term ambition and would feel like a more open and transparent discussion.  The talk I hear about parity is critical, I welcome every statement that people in the NHS make, but the announcement of a bit of money by politicians that describes parity as its aim misses the target for me.

I remember being in the States for a learning tour at Harvard several years ago.  I only had a working knowledge of the US health system before that and after it was still only limited, but I did get to understand one of the major issues over there is not the uninsured, but the underinsured - described to us as the Boston Taxi Driver issue.  People who can't afford to fully insure themselves for everything prioritise and choose what they want health insurance for.  Invariably they choose things that would keep them alive and that would allow them to carry on working and leave out less obvious issues, typically mental health treatment.  So they, like us, end up, through an entirely different system, deprioritising mental health.

Ultimately, I guess, politics is about us; if mental health rather than A&E won elections we would see greater investment and promises.  Until then will it always be fighting for parity?

Highlights of the Week - 10th October 2014 (@jeclo)

Highlights of the Week 1: What's a highlight? Fantastic reflections on what really is a week's highlight personally rather than a commentary
I set off doing this blog following weeks of just posting the 140 characters of my 5 highlights of the week on Twitter each week.  It moved from being a 3 minute activity to something a bit more considered; I wanted to explain what those highlights meant and to provide a bit of context and reflection. I've noticed that as I have written a bit more, it has gone from being the 5 true moments that were happiest in the week, to a crafted exposition that balances the tasks that I need to carry out.

It is important - the blog is "out there" so people might conclude that whilst the financial challenge mounts, I'm just laughing and smiling throughout and that deduction may have an organisational impact as well as personal.  But perhaps in that moment something of what I was and am trying to achieve gets a bit lost. 

This week I was showing the blog to a few people and re-read some recent posts, so had a pause to reflect and I determined to try to get back to the original ambition, whilst still recognising the implication of putting things in to the public domain.  There is a purpose to this and to bend it to be something else because of a concern that people won't be able to see different parts of what I strive to achieve doesn't feel like the leadership that I aspire to.  So more smiles from here on...!

Highlights of the Week 2: 22ours - a development space with fantastic, stimulating people. The only input is ourselves @ChooseYou2 @timrobson07 
I will have mentioned 22ours before; a group of development specialists that I meet with 3 or 4 times a year for an intense 22 hour learning set. The only resource we have is each other (we have crafted one workshop with Nancy Kline) and the agenda is emergent at each meeting, sometimes a bit more planned, but often totally spontaneous.  Often supportive, it has been the setting of some hugely challenging and searching sessions of feedback too.

But it is a great space - a place I went to when considering moving to Devon and giving up my business and a space this week for me to think through the impact of the kind of role that I carry out and the extent to which I am really adding the most I can in the way that I'm currently working.  Plenty of food for thought.

Alongside my move to the West Country the learning set has seen the writing of 3 books and this week was celebrating the sales of one reaching almost 10,000 (amazingly big for a first book in the development market), the imminent publication of the second and the nearing of a publishing deal on the third.

It felt like a an injection that will give the energy and resolve to make the biggest impact on the challenges and tasks ahead.  A reminder that pausing for breath is important.

Highlights of the Week 3: Finding your voice on Twitter - what does that mean? Is it really that hard? 
Some things that I find really hard, others seem to glide though without a second thought; but there are some things that I do fairly naturally that others seem to struggle with.  Deciding on your voice on Twitter is one of those.  I can't remember pausing for long to think about what I would want to tweet about or how I would want to express things.

I didn't contemplate tweeting lots of personal things - it simply isn't my style to broadcast that kind of information and I prefer the slightly more contained Facebook for that kind of interaction; I didn't think about following 2000 people so that I could get 1500 followers- it isn't the way I go about creating relationships; I don't favourite lots of celebrity tweets to try and get reflected fame; I did just decide to try and do what I would do anywhere else: be consistent, reliable and try to inspire (try to be occasionally funny, share a bit of vulnerability and then (work hard to) not worry about the reaction).

Of course it is an edited version of me-I'm not the same on Twitter as I am in work and am different again at home.  Ultimately, those are just contexts, the "voice" is just to be comfortable with the presentation of me in this particular space.

Highlights of the Week 4: Raising a smile before another event looking at how we move the huge challenges we have ahead of us forward
I looked out at the team at our planning event and the there was an immediate sense of people who are tired and working really hard on our financial challenge who are concerned about the future, worried about our ability to deliver the scale of change and just running to stand still.

I was about to move in to a session that would describe the next steps in our NHS Futures programme to deliver financial sustainability, will give an exposition of our financial position and implications and then try to work out how we synthesise the need to work collectively with our providers with our need to produce a CCG financial plan that balances and is robust.

And so I decide to spend 10 minutes changing the energy a bit; introduce a bit of humour and get the room laughing and smiling.  As we go round the room, people are asked to share increasingly funny stories as they introduce themselves, a very, very simple piece of facilitation.

When we finish I simply observe the importance of making sure as we work diligently on the stressful and all encompassing task of financial recovery that we have to look after our own state and the impact on us and our teams.

As I look back out at the team, it looks more like a group ready to start the workshop ahead.

Highlights of the Week 5: A meeting with the Exec Team at @PHNT_NHS.  Huge challenges but an atmosphere of possibility and desire to explore
Both the CCG and Plymouth Hospitals NHS Trust are in planned deficit this year - planned in the sense of being agreed with our respective assurance organisations NHS England and the NHS Trust Development Authority.  It means that when we get together, there isn't a lot of pausing on the successes before we look at the tasks we need to complete.  And everything is harder as neither of us has the flexibility to make a compromise or a deal if it worsens our individual financial positions.

This week though we did manage to spend at least some of our time together looking at where we might make progress together using the NHS Futures programme as the structure for a new way of working.  We also both acknowledged the basic philosophy we share in trying to improve services for those we serve, not always evident when we argue robustly about our different perspectives on a particular area of disagreement.

Small steps and progress - let's hope it counts for something as we head in to a new contracting round.

More smiles next week :-)

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.

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.