Week 10: Commissioning for Quality & Outcomes

The next @WeCommissioners live Tweet Chat at 8pm on 6 May is on the subject of Commissioning for Quality & Outcomes.  This is the current version of the pre-chat blog.

First a quick recap on commissioning: “Commissioning in the NHS entails decisions about needs assessment, resource allocation, service purchasing, monitoring and review.” Nuffield Trust, 2014.

Secondly, what is meant by quality and outcomes: In the NHS Next Stage Review, 2008, quality is defined by Lord Darzi as care which is "clinically effective, personal and safe".  Outcomes are the results of support activity or interventions for the person, not the activity itself; these can be measured or defined in a range of ways, including Patient Reported Outcome Measures (PROMS).  This specifically means outcomes for people in terms of how their health and wellbeing is safeguarded, improved or how they are affected by a specific procedure, course of treatment or other intervention.

The Commissioning Cycle has a number of stages where quality and outcomes are important to incorporate:

Historically, NHS services have been paid for through agreements and contracts based on the quantity of what is provided; more recently, the introduction of quality into these agreements has seen improvements and now there is a greater move towards payment based on outcome rather than quantity of service provided.  Yorkshire & The Humber Joint Improvement Partnership has some useful information and resources on outcome-based commissioning aimed at commissioners of adult health, wellbeing and social care services.  The approach to commissioning for outcomes is not exclusive to healthcare and commissioners of social care services are also moving further in this direction.  A seminar in January 2014 ‘Commissioning For Better Outcomes’ by the President of the Association of Directors of Adult Social Services (ADASS) describes how this works in this area.

The National Institute for Health & Care Excellence have produced a national Clinical Commissioning Group Outcome Indicator Set.  These are intended to “support CCGs and health and wellbeing partners to plan for health improvement by providing information for measuring and benchmarking outcomes of services commissioned by CCGs”

There are a number of tools at different stages of the commissioning cycle that are used to ensure a quality and outcomes focus to commissioning, specifically through the annual commissioning elements relating to contracting.  Requirements for quality and outcomes are specified to commissioners through the Standard NHS contract.  Once commissioners have identified the quality standards and outcomes that are to be achieved by a provider, it is through the contract that these are formally agreed.  Following this, there should be a robust and planned process for regular monitoring of performance against these standards to ensure they are being met.  For some standards where they are met, providers can receive additional payments from commissioners and for some where they are not met, commissioners can impost financial penalties.  These details are all specified within contracts.

Further Resources:

NHS England 2014/15 Commissioning for Quality & Innovation Guidance

NHS Library Service Commissioning Handbook for Librarians

NHS Confederation Briefing ‘Two sides of the same coin: Balancing quality and finance to deliver greater’

ADASS –Association of Directors of Adult of Social Services

Public Health Outcomes Framework 2013 - 2016

Social Return on Investment Network Intl

Outcomes Focussed Services for Older People, Social Care Institute for Excellence

Week 9: Continuing Healthcare

One of the central principles of the new NHS in 1948 was to be free at the point of need.  Aside from some notable exceptions such as prescription & dental charges, this continues to be the case in the NHS in England.  This principle has been questioned and challenged over the years; more recently by a suggestion that people could be charged a monthly ‘subscription’ fee.  Fortunately, so far, this isn’t formal Government, opposition or NHS policy.

Although NHS services are free to all at the point of need; who ‘qualifies’ as being in need doesn’t always equate to everyone, all the time.  There are many issues of geographical difference of services, often referred to as the ‘post-code lottery.  I may write a blog on that subject in the future, but this one is focussed on another element, namely continuing healthcare. This is when it is established that a person has complex and ongoing healthcare needs that should be met outside of hospital. People are assessed as to whether they qualify for NHS for this.  This assessment of need is done through a formal process; initially using a screening tool called a Checklist, which is used to identify whether a person requires a more in-depth assessment.  If so, then a multidisciplinary assessment is undertaken supported by a Decision Support Tool.

If a person, following assessment through the Decision Support Tool is identified as meeting the criteria for NHS funding, a ‘package’ of care is then commissioned to ensure that these assessed needs are met on a continuing basis.  The assessment is multidisciplinary, including health and social care staff.  There are e-learning tools available, aimed at both NHS and Local Authority staff involved in the process.  Each stage of the process is open for appeal and if someone has a more urgent need to get service in place quickly, i.e. for someone near end of life, there is a Fast Track process to ensure this happens without delay.

I attended an NHS England Roadshow this week for CCG Directors of Quality & Nursing and people from the NHS & Local Authorities responsible for commissioning Continuing Healthcare.  The focus of the event was a new Quality Assurance Framework, which is yet to be formally published.  The framework is intended to assess both the quality of the assessment process and the quality of service received through a series of prompts.  This is intended to form part of and not to replace local quality assurance systems.  The prompts have two distinct features:

1.      Firstly, they are set out as a series of statements starting “I...”, as quality should be assessed from the perspective of the person receiving the assessment and the continuing healthcare itself; or their family/carer(s).  For example: “I felt the assessment focused on me as an individual and helped me live the best life I can” and “I am supported to have choice and control wherever possible over my care and support”.
2.      Secondly, the framework is built around the ‘Six Cs’, i.e. the prompts are separated into six category headings: Competence, Courage, Commitment, Care, Compassion, Communication.

As a group of Directors of Quality & Nursing from our local area (Hertfordshire & South Midlands), we agreed at the Roadshow that we needed to do more work locally to ensure that we consistently embed this assurance framework into our quality assurance systems.  We committed to doing this collectively.

Finally, but very significantly, since 1 April 2014, all recipients of continuing healthcare are entitled to request a Personal Health Budget(PHB).  This allows individuals to directly ‘commission’ their own NHS-funded package of care, personally selecting the agencies and sometimes individuals who will meet their needs.  NHS England’s vision for personal health budgets is “to enable people with long term conditions and disabilities to have greater choice, flexibility and control over the health care and support they receive”.  PHBs were originally piloted and have been evaluated.  The website for the evaluation project and the final report contain a lot of detail on what was found.  In summary, the pilots showed that people had: more control, greater choice, better care-related quality of live and significantly lower cost.

Week 8: “It’s the economy, stupid”

NHS Clinical Commissioning Groups (CCGs) are the part of the NHS responsible for commissioning health services for a local population.  In simple terms, this means assessing need, purchasing services and ensuring NHS funded service providers achieve required quality & outcomes.  Some health services like primary care (GPs, Dentists, Pharmacists & Optometrists) and specialised services, such as renal (kidney) dialysis services as well as neonatal care, severe burns care and some mental health and children’s services are commissioned by NHS England while public health services are commissioned by local authorities and Public Health England.  One key function of CCGs and all commissioning organisations is to make the best use of the resources available to them, i.e. spend NHS (public) money wisely on behalf of the population they serve.

This week CCGs were one year-old on 1 April 2014 following the NHS reforms in England.  The Kings Fund and The Nuffield Trust marked the occasion by writing 'How engaged are CCG members one year on?’ and ‘Clinical commissioning groups – one year on’ respectively.  Where I work in Luton we have had productive year developing the CCG into an organisation more focussed on the needs of the people of Luton who we’re here to serve; building on the fantastic work done whilst in ‘shadow’ form the year before (that’s a lot less sinister in reality than it sounds!).

One challenge we started the year with that remains with us is the constraints of the financial resources we have available to us.  This second year for Luton CCG will be equally financially challenging. I know that’s an oft heard refrain in the NHS and the wider economy, but let me explain a bit more about why this is a specific challenge in Luton.  In Luton, the services paid for by the CCG, in the financial year that ended on 31 March 2014, have cost more money than we received from Government and therefore ended the year with a deficit.  The exact size of this deficit is yet to be determined, as we’re still ‘closing the accounts’, i.e. doing all the final sums to identify exactly how much more have we spent than we had coming in.  At our Public Board meeting in February 2014, the forecast deficit was predicted to be £5.3M.  This is not the first year this has happened in Luton and based on the current accepted formula Luton receives about 7% less money annually than it should compared to other areas of England (NB CCGs receive our funding from Government, i.e. publicly funded through taxation).

There will be a modest increase in funding for health services in Luton commissioned by the CCG over the next two years, but this will only partially close this funding gap.  By 31 March 2016 (two year’s time) we are expected have to not only ensure that what we spend matches what we receive, but we’re required to make a 1% surplus each year (end the year with having spent less than 99% of what we receive from Government) for investment into new services.  Unlike in previous times in the NHS, there will be no bail-out from the powers above us and whilst we have locally secured ‘brokerage’ (a short-term loan from other nearby commissioning organisations) we have to not only pay this back in the next year, but we also to reduce the amount we spend more than we’re allocated.  This doesn’t equate to cutting services, but to being more innovative and efficient about how we use the money we do have, including through an approach called QIPP (Quality, Innovation, Prevention & Productivity).

This is a significant challenge and there is a great deal more complexity in this than is summarised in this blog but we’re up for the challenge.  We fully intend on meeting the tough standards we’re required to achieve and those we’ve set for ourselves.  Our plans for the coming year, and beyond, will ensure we work with local people and clinicians to be more focussed on the needs of the rich diversity within Luton to improve their health and outcomes.

(PS this blog is not intended to be a master class in NHS finances – if you want to read more about NHS finances, the NHS Confederation has some helpful resources.)

Week 7: Does Nursing Have A Self-Image Problem?

Roy Lilley's daily blog on Tuesday 25 March was about the problem he has with compassion, which he sees as too superficial and lacking substance. He questioned whether 'love' would be a suitable substitute asking: "Can we do love in the NHS?".  Whilst I don't entirely agree with Roy and I do truly believe that compassion can be taught, developed and nurtured in many; this got me thinking about whether there's an issue with how the public perceive nurses.  Much media coverage of nurses continues to be either negative news stories about the tiny minority involved in scandals or frivolous representations.  This is a significant driver of public opinion.  Along with many others, the Royal College of Nursing is trying to provide positive images of nursing to the public and the profession through the This Is Nursing campaign.

Beyond the media and the public is nurses' own image of themselves and the profession.  I make no apologies that I will include generalisations in this blog.  I am well aware that nursing is a complex profession made up of many diverse fields and a multitude of specific roles; however, in this short post I will generalise for illustrative purposes.

After reading Roy's blog and then seeing a meme on Facebook; on Wednesday evening I tweeted, intending to provoke discussion about the values and qualities important to nursing.

Sometimes I am deliberately provocative in what I tweet to see the response that arises and to stimulate debate.  I don't always necessarily personally subscribe to every view I tweet, but am always interested in others' thoughts, feelings and opinions.  It was Trish Greenhalgh, shortly after I joined Twitter, who said that it is important to follow people whose views you don’t agree with to avoid groupthink.  It is the diversity of Twitter that makes it so interesting.

At the time of writing this blog, the tweet in the image above has over 160 retweets, almost 100 ‘favourites’ and also sparked an interesting debate about whether this sentiment devalued the skills & intelligence of nurses.  During this debate, I tweeted "IF you had to choose between 2 essential nursing attributes: RT for Care/Compassion or Favourite for Intellect/Skills (hypothetical Q only)".  This furthered the discussion with the majority of responses being along the lines of 'can't choose/won't choose'; however, of those who did make a choice one way or the other there was a small majority in favour of compassion over skill.

What was particularly interesting to me about the high number of retweets, the choices made in replies and the discussion that took place was that this mainly involved nurses along with invaluable participation from others.  This then got me thinking further about whether nursing as a profession has a self-image problem.  Whilst I don't want to second-guess the motivation of most people who retweeted or commented, but for the purpose of drawing a conclusion, I will assume that many did so in agreement with the sentiment expressed (some retweets did include comments like "so true!" so I feel I'm on fairly safe ground with my assumption).

A few, but far from the majority, of people who engaged with and me about this expressed a view that this overall response and many other frequently tweeted and retweeted sentiments are causing a problem.  The theory put forward was that by perpetuating a self-image of nurses as super-hero angels who hold people's hands and talk soothingly to them leads to a suggestion that the profession is less skilled and competent than it is.

We now have degree-only entry into registered nursing with many universities and employers using values-based tools to recruit new nurses to ensure we get nurses who have compassion and competence.  At risk of becoming a mouthpiece for the 6Cs it is essential that all six of the Cs are present and valued by nurses and nursing as a profession (two of the Cs being Compassion and Competence).

I'm not sure if nursing does have a self-image problem; I'm not personally connected to enough of the profession to form a view (and I'm probably not qualified to assess it either – greater research minds than mine may be needed here).

So nurses, academics, people of England and the world, carry on the conversation; does nursing have a self-image problem? If it does, does it matter? If it does and it matters, what’s to be done?  Discuss…

Week 6: Nurse Leadership in Commissioning

At 8.00pm on Tuesday 25 March @WeCommissioners, along with @WeNurses and @6CsLive are hosting a Twitter chat on the opportunities and challenges for nurse leaders in commissioning. The chat will explore this in more depth, but as some pre-reading, this blog will explore the different roles of nurse leaders in commissioning.


Nurse leaders come in all shapes and sizes and this is no different for nurses working in commissioning. Those nurses working in commissioning roles come from a diverse range of backgrounds and do a wide variety of roles. This includes engaging with patients, public, professionals and colleagues to design new services, improving existing ones, to monitor the quality and to ensure good governance of services.


Whatever the background and role of nurse leaders working in commissioning there is one thing that they all have in common; a drive to improve things for people. At the start of most commissioning nurse leaders’ careers they were student nurses and I doubt many, if any, at that stage intended on working in commissioning roles. There are many and varied routes into working in commissioning for nurses and they have had key leadership roles right from the start of the NHS and specifically in commissioning following its introduction in 1991. Since then organisations responsible for commissioning have involved nurses in key leadership roles. Today there are a huge range of roles for nurse leaders in health and wellbeing services commissioning, mainly in Clinical Commissioning Groups, NHS England and Local Authorities. These include, but aren’t exclusive to: Nurse Board Member, Director of Nursing/Quality; Quality Lead; Patient Experience Lead; Patient Safety Lead; Infection Control; Safeguarding Lead (Adults & Children); and many other roles not exclusive to nurses, but requiring clinical experience & knowledge.


The underpinning leadership skills required by nurses working in commissioning are not that different to those working in leadership outside of nursing and nurses working in other parts of the health service. Forbes describes the 10 key attributes of great leaders and these apply equally well to nurses working in commissioning as to other professionals and disciplines:


Honesty
Effective Delegation
Communication
Sense of Humour
Confidence
Commitment
Positive Attitude
Creativity
Intuition
Ability to Inspire

Do these ten qualities sound familiar? They is significant overlap with the 6Cs (Care, Compassion, Communication, Competence, Commitment and Courage), which apply equally well to nurse leaders in commissioning as in any other field of nursing. Finally, being a nurse leader in commissioning doesn’t equate to seniority. The attributes described in Forbes in the list above and through the 6Cs are applicable to nurses working at every level in commissioning. It is important that we recognise the value of this, provide more opportunities for nurses to experience commissioning roles from pre-registration training through professional practice and at any stage in a nurse’s career.


Nurse leaders working in commissioning roles have great opportunities to change things for the better for patients, public and colleagues within the NHS. There are also significant challenges in these roles and they involve some very difficult decisions, daily. Through the chat we will explore what some of these opportunities and challenges are and how they can best be approached.

Further reading & resources:
Commissioning Nurse Leaders Network
Webinars on commissioning topics for nurses
NHS Careers; Careers in management, including nurse leadership roles in commissioning
Healthcare Professionals Commissioning Network
For more detailed background history of the NHS, including commissioning

Week 5: ‘People’ Experience

No free gift this week I’m afraid, but there is a challenge for you, at the end of my blog this week.

The results of the 2013 NHS Staff Survey have been published.  The response from NHS Employers celebrates improvements, but openly acknowledges areas the NHS still needs to improve on.

Staff experience is a really important area and we have been looking at the results of the survey relating to our CCG staff and those of our local providers.  We’re seeing how we can use this information in our organisational development plans to improve the experience of people working for us.

Both where I work and in the wider NHS, there is still a lot to do to improve the experience of staff.  This includes looking at how we can be more open and transparent, as discussed in my postlast week.  In recent times there has, quite rightly, been significant focus on improving care, outcomes and experience for patients.  There has also been much activity aimed at improving staff experience, but not as much as that aimed at patients.  For those more directly involved in the NHS, you will recognise that much of this has come ‘post-Francis’.  I don’t mean to belittle the significant work done before this to improve staff and patient experience, but this has driven the focus in the past year.

I believe that we should look more holistically at ‘people experience’ and not always separate out patients and staff when we address at how our organisations ‘behave’.   An organisation’s culture is made up of the collective behaviours of staff within it towards each other and to patients, carers, the public and others who we work with day-to-day.  If we take a more rounded view of our values and behaviours; what drives us and influences our organisational cultures we will see that these probably don’t differ too greatly in terms of staff or patients.  If we want to show compassion and achieve positive outcomes for patients (and we do!); then we should do the same for staff. 

If we set up project groups, working parties or task and finish groups just in response to survey results trying to ‘fix’ problem areas we will not make the changes we need to really make a difference.  We need to look at the staff survey results alongside other sources of information about how others experience the behaviours and cultures of our organisations.  If patient surveys say that there are issues with how we communicate with patients and staff surveys say the same; there is something quite fundamental that we need to address about communication within the organisation.  ‘People Experience’ is not a new concept outside of the NHS so we can learn from those who do it well.  For example, FirstDirect have been doing this for years, i.e. driving improved experience for their customers directly through how they treat and engage their staff.

There is an opportunity for NHS organisations to do the same; really invest in staff, focus on their experience; senior leaders treat staff how we expect them to behave with our patients.  I know there’s a lot of rhetoric about leadership and culture, but I truly believe that if members of NHS Boards do this right it will have an amazing impact.

So, I challenge you to find out whether your local NHS organisation (or your employer if you work in the NHS) has set up a ‘Staff Survey Working Group’ or similar, exclusively looking at the results and with the intention to draw up an action plan of how to address these issues in isolation.  If you find this to be the case, ask whoever is the most senior leader responsible for this area how this will be integrated into work that you will inevitably also be doing on patient experience.  Do suggest that there may be value to both areas and therefore to staff & patients to look at these together.

Week 4: Opening Up For NHS Change Day & the UpGoer5

READ TO THE END FOR A FREE GIFT!!!

NHS Change Day

Last year a single tweet (not by me I hasten to add!) sparked an idea that led to 189,000 people making personal pledges to change something in to improve the NHS for patients.  This was the first NHS Change Day.  March 3rd 2014 is the second NHS Change Day where the aim is for over half a million pledges. Before it's official launch on March 3rd we are already over half way to this target.

Being Open With Patients

This year, as well as supporting pledges made by others, mypersonal pledge is about improving the openness and transparency of the NHS.  The NHS has a chequered track record on being open.  The National Patient Safety Agency originally published guidance in 2005 on communicating effectively with patients when things go wrong, under a headline of Being Open.  Since 2009 it has been it has been a key requirement of the NHS Litigation Authority, who provide insurance cover for all NHS Trusts, that they have well designed policies to help ensure they are open with patients and families when things go wrong (requirement 2.10 of the NHSLARisk Management Standards).

In April 2013 it became a contractual requirement for providers of NHS services to be open with patients and their families when they suffer serious harm through a contractual duty of candour (section SC35 in the StandardNHS Contract).  It was a recommendation of Sir Robert Francis’s report on the public inquiry into failings at Mid Staffordshire NHS Foundation Trust that there should be a statutory duty of candour.  The government, in theirresponse, said they will pass laws to introduce this.

NHS Board Transparency

The Professional StandardsAuthority Standards for members of NHS boards and Clinical Commissioning Group governingbodies in England require that board members, and therefore boards, are open.  It states:

“I will be open about the reasoning, reasons and processes underpinning my actions, transactions, communications, behaviours and decision-making and about any conflicts of interest”

In spite of all these guidance, requirements, contractual duties, standards and impending legislation, some parts of the NHS on some occasions are still not as open and transparent as we should be.  I deliberately say ‘we’ because I take personal responsibility for the actions or inactions within my power to change where we are not open in the best interest of patients and public.

This is why my NHS Change Day pledge is to challenge any lack of, or perceived lack of, transparency or openness that I come across.

Using Open Language

Another significant way in which the NHS can be less than transparent to patients and the public is in the language that we use.  During last night’s WeNursesTwitter Chat about ‘standardised languages’ part of the conversation turned to the jargon, abbreviations and acronyms that health professionals use on an all too frequent basis.

As a key part of my pledge, I aim to challenge others and reduce my own use of unexplained jargon, abbreviations and acronyms.  One conclusion from last night’s chat was that the use of jargon can alienate people, engaging with people in a language they understand is essential to build rapport and ensure they are not disempowered.  Nelson Mandela once said:

"If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart."

Sometimes not using complicated language can be difficult.  If you want to see in practice how hard this can be; try using the Up Goer 5 tool to explain any every day concept, object or idea.  It will only let you use the most often used ten hundred words.  This idea came from a challenge to explain the Saturn V rocket in simple terms.  An explanation of the story is here.

Week 3: Sequins & Values-based Commissioning

I wrote previously about CQUINs (pronounced: ‘see-kwin’) on Day 38 of my 100 day blog, but this post really is about sequins (partly)!  Watching the Winter Olympic Ice Dance with my wife, brother-in-law and sister-in-law we were a little perplexed by the scoring system.  A simple question arising of: “what’s the maximum possible score” led to furious Googling and unsuccessful efforts to find a straight answer to this seemingly simple question.  With no assistance offered by the commentators and not to be defeated, I eventually found the International Skating Union website and their “Special Regulations & Technical Rules: Single & Pair Skating And Ice Dance 2012”.  Buried deep within multiple sections of this 169 page document it states that there are nine judges on an Olympic judging panel and each may award up to 10 points; therefore, a maximum total score of 90 is available for the short programme.

Through searching for the answer to a relatively simple question, I came across a cloud of technical detail and complexity.  This reminded me of the NHS Standard Contract.  For which annual negotiations with providers are currently in full swing.  Although we already have providers in place for the services we are responsible for, there is an annual process of agreeing some significant elements to reflect changes in our local requirements and nationally mandated priorities.  The full technical requirements are within the NHS Standard Contract, which itself runs to 210 pages in template form.

Annual negotiations centre on the detail of what is important to local people who use the services and any particular issues that may have arisen in the last year not specified previously and which require specifying in the contract.  This all adds up to a lot of complexity and much debate over the detail between commissioners and providers.  Where more than one commissioner or provider is involved this can get even more complicated.  What is missing from this process is an explicit application of values to underpin decisions.

I fully understand that within the NHS ‘internal market’ between commissioners and providers and for many legal reasons, a lot of the technical detail is necessary.  I also understand that this is borne out of how the ‘system’ has been set up and how regulators, such as Monitor and NHS England require the process to take place.

It’s probably too late in the process for this year’s annual contract negotiation process between commissioners and providers, but in future years, it should be possible for us to start by establishing shared values for use throughout negotiations.  The intention being not to have a big stick to beat each other with, but a simple reminder of why we’re doing it before we get too lost in the technical detail.  This is important as an important element of making change across organisational boundaries is to ensure a shared vision and common set of values.

Finally, it is worth noting that rule 353.1.m.ii of the ISU Special Regulations & Technical Rules states: a deduction up to -1.0 point may be made if part of the costume/decoration (including sequins) falls on the ice.

Week 2: It started with a tweet…

This is the tweet that started it:

I wrote about this tweet on day 96 of my 100-day blog.  The response I got and subsequent conversation on twitter is summarised here, produced brilliantly by Clare Helm.

The response, whilst containing great examples of health service providers using social media for patient benefit, wasn’t full of a huge amount of similar examples by commissioners.  There was however a need identified for more support for commissioners in this area.  Following this Clare Helm had the idea that we could set up an online community through Twitter for commissioners to share ideas and spread good practise.  From there @WeComissioners was born.

As part of the WeNurses family, there will be WeCommissioners Twitter chats every two to three weeks.  I’ll be supporting running this with, amongst others the wonderful Clare Helm, who works at NHS England supporting CCG development (although WeCommissioners isn’t formally part of her day-job).

Our first live Twitter chat is 8-9pm 11 February.  Do join us; there’s helpful info on how to join a Twitter Chat here.

For this first @WeCommissioners chat we want to talk about collaboration in commissioning.  We intend on this chat being open to discuss any element of collaboration that is of interest and value to you.

Commissioning has emerged as an increasingly important driver of quality, efficiency and outcomes for patients in the past 10 years.  Commissioning put simply is how we plan, agree and monitor services; including procurement where this is needed as part of the process.  Due to the complex nature of health and social care services, this is much more complicated in reality.  This can include a number of inter-related activities ranging from assessing the needs of a specified population, through the clinically based design of patient pathways, to development and agreement of detailed service specification and contract negotiation or procurement, which is subject to continuous quality assessment (taken from commissioning information on the NHS England website).

To get the best outcomes for patients, to ensure services are safe, effective, provide a valued experience and to ensure the most effective use of public money, commissioners must collaborate.  The, now not-so-new, NHS structure means that different organisations need to collaborate to achieve shared goals and to best safeguard the public.  Achievement of the aspirations for patients and the public described in the respective outcomes frameworks for the NHS, Social Care and Public Health require significant collaboration between organisations locally, regionally and nationally.

Before the chat, it might be helpful start to think about the following questions:

• what collaboration means to you;
• how commissioning organisations should collaborate;
• who should commissioning organisations collaborate with; and
• what lessons have been learnt previously about collaboration that we can benefit from?

Some further background reading that may be of interest prior to the chat:

• Better Care Fund (previously Integrated Transformation Fund)
• Framework of Excellence in Clinical Commissioning for CCGs from NHS England
• Better Collaboration for Better Healthcare in HSJ March 2013
• Kings Fund resources on Integrated Care
• Lambeth Collaborative Commissioning Model

Week 1: ENTJ

At a Board development session earlier this week we discussed the results of recent Myers Briggs personality type tests we had all taken.  The purpose of this was for us to gain more insight into ourselves as individuals, the Board collectively and how we relate and interact together.  We want to work more effectively as a collective Board through being aware our strengths and where there may be gaps or less prevalent personality types we need to accommodate for.  Before you get too excited, this blog isn’t going to be a tell-all story of what my fellow Board members’ personality type results are; I’ll leave them to decide whether to share this information in public or not!

For anyone not familiar with Myers Briggs, essentially it is a way of identifying your preferred personal style in four dimensions, which defines how you perceive the world and make decisions.  A simple survey is completed by an individual, then scored resulting in a four-letter description of your ‘type’ from the four different dichotomy scales, as shown below:

Dichotomies
Extraversion (E)	–	(I) Introversion
Sensing (S)	–	(N) Intuition
Thinking (T)	–	(F) Feeling
Judging (J)	–	(P) Perception

From the above dichotomies there are 16 different personality types (shown below).  This doesn’t mean any individual is restricted to behaving in a particular way, but the scored ‘type’ just defines their preference for how they perceive the world and make decisions.

From the scoring, my type came out as ENTJ, which means I have a preference for Extroversion, Intuition, Thinking and Perception.  This doesn’t mean I can’t practice and use skills or attributes associated with Introversion, Sensing, Feeling or Judging, only that these aren’t my preferred styles.

This outcome for me was no surprise and is consistent with the three times I have done this before in the last 15 years.  The most interesting thing for me to reflect on now is how this applies in my current role and how I relate to colleagues internally and externally.  I also want to take time to think through how using knowledge of my preference can help me to be more effective.

As an ENTJ most of my weaker characteristics stem from my dominant Extraverted Thinking, the E and T in my type.  These can overtake my personality, stifling the natural expression and balancing value of the other personality functions.  Because of this I am aware that I may:

·         Find it hard to understand other people's needs where these differ from my own.

·         Become so engrossed in a plan or ambition that personal needs and the needs of others are forgotten.

·         Take every decision not made in agreement with my rational beliefs as a personal rejection.

I am aware of this, which is a start, and will make efforts to try to counter these perceptions and how they influence my behaviours and decisions where I can.  I’ll be doing a similar exercise in the near future with my direct team to help us work better together.