What does it take to be a leader?

I’ve spent a lot of time this week thinking about leadership.

This was prompted by two significant things: firstly I was Acting Chief Officer while my boss took a well-earned break; and secondly I attended a feedback session for survey results as part of my participation in the NHS Leadership Academy  Top Leaders’ Programme.

Prior to the feedback I had to undertake a series of ‘diagnostic’ tests. It wasn’t as scary as that sounds, but included me seeking 360 degree feedback through an online survey from a range of colleagues; completing my own version of this survey and also taking tests on the following:

• Verbal Reasoning
• Numerical Reasoning
• Organisational Climate
• Leadership Styles
• Career History & Mobility
• Personal Dimensions

This was the first time I’ve had proper 360 degree feedback through a formal anonymised process, so was really looking forward to some insightful and honest views. I wasn’t disappointed, as my colleagues were generous with their praise for my strengths and clear and genuine in identifying areas for my development.

The purpose of the ‘diagnostic’ feedback session was to work through the 360 degree feedback alongside the results of the other tests/surveys I had undertaken to look for key messages and themes for me to work on throughout the Programme. Whilst it was tempting to try to read too much into individual elements of the results or single comments, I was helpfully steered through the themes and have much to work on for my development and to support the development of those around me.

 

You have to leave your ego at the door to really hear the messages of the feedback and to be open to change to become a better leader.  One key thing I took away from the feedback session was confirmation of the amount of work and effort I need to put in to be the leader that I want to be. It has really helped me to focus on the areas of change that I can make in myself, my attitudes and behaviours to have the best impact whilst remaining true to myself, my values and beliefs.

 

I have some work to do to make some changes now, but will have more opportunity to explore the themes from the diagnostic tests further with my mentor and at the first proper sessions of the Programme in late November. I am looking forward to meeting my fellow 'cohort 18' participants from around the NHS and to learning from their different perspectives and experiences, as well as offering my support to them.

I'll keep you posted on my progress...

 

#TANTT – Teach A Nurse to Tweet Tuesday

Today is Tuesday. Today, @WeNurses, I and others supported nurses to learn to use Twitter.  This was Teach A Nurse To Tweet Tuesday, which is a weekly campaign.

The benefits of nurses using Twitter are many and broad. This greatblog by @Gray3Gray explains her journey in discovering the value of Twitter to health professionals.

To support and encourage more nurse leaders working in commissioning to engage with each other, other nurses and the public through social media, I recently ran a webinar for Commissioning NurseLeaders’ Network on The Basics of Twitter.  A recording of this webinar is available online here.

If you don’t have an hour to watch the recording of the webinar, my top 10 tips for getting started with Twitter are:

1.    Sign-up and in your ‘Profile’; say who you are, what you do & what you tweet about.  This helps others find you, see what you’re about & decide whether to connect with you.

2.    No ‘disclaimer’ is needed in your profile, people will assume you’re tweeting your own opinion, unless you state otherwise.  Adding a disclaimer is not really necessary and wastes some of the valuable character limit within which you should describe yourself (see tip 1 above).

3.    When you first sign-up to Twitter, you will be represented by an image of an egg, which you can replace with any image you want.  Hatch from your egg & add a picture of yourself to your profile.  People want to connect with people, not eggs.

4.    If you’ve newly signed-up to a Twitter account, don’t immediately follow hundreds of people without tweeting, as people may think you’re a spam-bot and could block you, especially if you’re still an egg (see tip 3 above).

5.    Retweet things you find interesting, they don’t have to reflect your views, but be of interest to you & your followers.  People will not assume that you always agree with everything you retweet.

6.    Follow a range of people with differing views, not just those you share.  The power of Twitter is the diversity of opinion.  This helps avoid you limiting your view of the world to a small group of people who think exactly like you.

7.    Do you know your RT from your MT or your DM from your HT? Learn the lingo, at least some the common stuff, so you know what others area talking about! Here’s a link to Twitter’sGlossary, which is a good reference point if you don’t understand any jargon or abbreviation you see.  If it’s not in this glossary, it may not be Twitter jargon and thisblog-post may be of assistance:

8.  Use the many free resources available to get the most from Twitter, such as Twitterversity from @WeNurses

9.    Create, use & follow lists to find & connect with groups of people; here are my lists.

10. When you Tweet: THINK FIRST:

 

Once you've started using Twitter you may want to consider joining a Tweetchat, which is a pre-organised facilitated discussion on a set topic. Here's a Simple Guide to Tweetchats.

Finally a brief plug for an NHS Employers blog-post of mine, this time with Teresa Chinn, about the myths of Twitter, which may help to encourage the more sceptical of you to give it a try.  An Infographic of the post is here on the @WeNurses Pinterest Board.

 

 

Incidents, Seriously?

When something goes wrong, the NHS has a responsibility to learn from it and to prevent it from happening again. When this results in serious harm to anyone, the weight of responsibility to learn and improve is even greater. Within the NHS we call these Serious Incidents and each NHS organisation has a policy through which these are identified, investigated, lessons learnt and improvement made to reduce the risk of recurrence.

All local NHS organisations’ approach to managing Serious Incidents stems from the national Serious Incident Framework. This is ‘owned’ by NHS England and was originally established in March 2013 for a relatively new organisation to lead the process throughout the NHS in England. It is currently under review and it is recognised that a much greater focus is needed on the learning from serious incidents whilst also ensuring a consistent and proportionate approach to investigation and incident management. Key to this is to put the patient and/or family at the centre of the process and to ensure that they are involved as much or as little as they want to be in this.

This week I attended a meeting as part of the NHS England Patient Safety Team’s consultation with staff from commissioners and providers in our local area. This was to talk to us about the current review of the framework and get our feedback on the latest draft. It was a great opportunity for us locally to influence how this evolves nationally and for the national team to get a feel for how things work at the front-line and to ensure that the framework reflects practical realities. This was only one of a series of meetings that the national team were running to engage with staff who have good practical experience of managing serious incidents and the background evidence of what works and what doesn’t to improve outcomes for people.

Inevitably, the discussion about the proposed new framework got into some of the detail of what will change and what won’t, such as: Will or won’t commissioners require providers to submit update reports 72 hours after the incident is discovered? Will all Grade 3 pressure ulcers continue to be deemed as serious incidents? What will change on the list of Never Events, and will this form part of the framework or be kept separate? How will disputes be resolved where a commissioner and a provider don’t agree as to whether an incident is ‘Serious’ or not…

Personally, the most valuable part of the conversation was when we discussed the overarching values and principles that should form part of the Framework. If we try to legislate for every single minute detail or circumstance that may occur; firstly we’ll never see the revised Framework, as it will take a decade to write and secondly, it will be the size of several volumes of the Yellow Pages! However, if those principles and values that over-arch and underpin the framework are clearly stated and agreed by those operating within it, any issues not specifically detailed in an appendix or flow-chart should be easily resolvable.

Ultimately, I believe that the following two things are most important in this:

1. Ensuring that the person involved in the incident and/or family is at the forefront of the minds of anyone involved in investigating it to ensure they are treated with dignity and compassion throughout. The needs of the individual should come above protecting the reputation of any organisation; and

2. A rigorous focus on learning at all levels must be applied, to include those directly involved, local services, units, organisations, wider local stakeholders and feeding into a system to genuinely contribute to learning across the NHS to reduce risk in the future.

[EDIT]

SInce writing this post, I have become aware of a consultation by the Care Quality Commission on draft guidance on implementing the new regulations on 'Fundamental Standards'.  This includes a Fit & Proper Person Test for people sitting on providers' Boards.  The following is a section from the guidance that describes the requirements for a fit and proper person:

"In addition to the usual requirements of good character, health, qualifications, skills and experience, the regulation goes further by barring individuals who are prevented from holding the office (for example, under a directors' disqualification order) and significantly, excluding from office people who:

  "have been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity, or discharging any functions relating to any office or employment with a service provider".

This is a significant restriction. It will enable CQC to decide that a person is not fit to be a director on the basis of any previous misconduct or incompetence in a previous role for a service provider. This would be the case even if the individual was working in a more junior capacity at that time, or working outside England."

The full consultation details are here.  The relevance of this to my blog-post is that any person who has a history of covering up NHS failings may (should) find themselves barred from holding senior posts in the NHS in the future.  Interesting article in Telegraph online here.

They Came, They Saw, They Inspected

On Thursday last week I received notification that on Monday (this week) the Care Quality Commission were coming for a week to inspect Child Safeguarding and Looked After Children’s Health Services.  The CQC are the regulators for all health and adult social care services in England.  They have previously done these inspections jointly with Ofsted and therefore have included Local Authorities and Children’s’ Social Services in their scope; however, this inspection was just the CQC.  Therefore, whilst they did include health services that are commissioned by the Local Authority, their scope to make recommendations for these is limited.

The notification last week initiated a flurry of activity from my CCG colleagues and our providers to prepare for the inspection this week.  We needed to provide a range of documents as evidence in advance.  We also needed to identify a group of ‘cases’ that met certain criteria to enable the inspectors to see records of and speak to children and families who had used a specific range of services.

This week started with the inspectors meeting with me as the Executive Lead for Safeguarding within the CCG and with our Designated Nurses and Designated Doctor.  We agreed the programme for the week with the inspectors aiming to visit as many relevant services as possible to speak to staff, patients, families and to look at records.

The following are the services that they visited:

• Midwifery
• Health Visiting
• A&E
• School Nursing
• Child & Adolescent Mental Health
• Adult Mental Health
• Contraception & Sexual Health
• Drugs & Alcohol

Throughout the week our Designated Nurse for Safeguarding Children and I had regular briefings from the inspectors on what they have seen and heard.   As a normal part of the inspection process any major issues requiring immediate action are highlighted to commissioners.  Throughout the week there have been no major issues that have required immediate action.

Today we got some verbal feedback at the end of the inspection.  We will receive a draft report to correct any factual inaccuracies within a couple of weeks.  The final report, including any recommendations will then be publicly published.  The feedback today was generally positive and in particular, the inspectors were complimentary of the committed and passionate staff who they had met throughout the week.

There were a number of areas highlighted by the inspectors that they will make recommendations on in their report.  None of these are issues that we weren’t previously aware of and already taking action of one sort or another on.  To follow-up the findings of the report we will ensure that there are robust plans in place to address all of the issues that were raised.

It is fair to say that the process of the inspection was challenging and hard work for a wide range of people across the NHS, the Local Authority and other services involved.  The result of this process will be for us to refocus our efforts in the areas identified by the findings of this inspection and to provide the public with assurance of how children are safeguarded and Looked After Children’s health is supported in Luton.

Competitive Dialogue

The technical detail of NHS procurement is not going to make the most inspiring blog for the majority, so it’s with trepidation that I write this post about what we’re doing in Luton at the moment.  Due to the specific procurement process I’m writing about still not being complete, I have to be careful about some of the detail, but I will either update this post in the future, or write again on the subject (unless there’s a significant ground-swell of opinion that I don’t!).  If you do want to read about some of the more technical details, the Procurement, Patient Choice and Competition Regulations are what you’re after.  These regulations implement Section 75 of the Health and Social Care Act 2012 and are updated by more recent European Regulations.

Clinical Commissioning Groups (CCGs) are clinically led local organisations that know the area in which they are working, and so are able to commission services that are specifically required by the population that they serve.  CCGs are responsible for commissioning the following services in their 'patch':

• Urgent and emergency care (for example, A&E);
• Elective hospital care (for example, outpatient services and elective surgery);
• Community health services (services that go beyond GP);
• Maternity and newborn; and
• Mental health and learning disabilities.

CCGs can commission services from a range of providers, including from the voluntary and private sectors.  Anybody that provides these services must be registered with a regulating body, such as the Care Quality Commission.  That’s a terribly brief description of CCGs adapted from NHS England’s Understanding the New NHS; more detail on the full commissioning cycle here.

When a CCG is ready to ‘procure’ (buy) services as part of its commissioning of services, there are a four possible procurement procedures used to award contracts under the legislation and regulations cited above, which are:

• ·     OPEN – The open procedure is suitable for simple procurements where the requirement is straightforward and the provider market is not very large. It is most commonly used in practice for the purchase of goods where the requirement can be clearly defined. As there is no "pre-qualification" of bidders, anyone can submit a tender and it is possible that a large number of provider will bid. The open procedure is more suited to a small provider market.
• ·     RESTRICTED – Consider the restricted procedure where you want to "prequalify" providers based on their financial standing and technical or professional capability so as to narrow the number of providers permitted to submit bids. Where the restricted procedure is appropriate, you should be able to specify your entire requirement now such that, based on your invitation to tender, bidders will be able to deliver a fully priced bid without the need for any negotiations following receipt of the bid.
• ·     NEGOTIATED – Following the Public Contracts Regulations 2006, the negotiated procedure can only be used in extremely limited circumstances, for example, where the contract is for a genuinely unique type of solution and there is only one capable provider in the market;
• ·         COMPETITIVE DIALOGUE – The competitive dialogue procedure can only be used in limited circumstances. It may be appropriate where: (1) the contracting authority is unable to produce a complete specification of requirements without discussing its needs in detail with providers (but iterative discussions with bidders should allow a detailed solution to be specified); and (2) where the solution is likely to be particularly complex and will require dialogue with bidders to conclude. The competitive dialogue procedure is generally used for very complex procurements.

If you’re still awake, congratulations, thank you and now keep reading...

The Luton CCG Board took a decision that in reprocuring our mental health and community services we would use the Competitive Dialogue process.  This decision was based on both the complexity of the services and our desire to work with potential providers to develop specifications for the services based on their expertise of what was innovative, possible and personalised to the needs of local people.  The way that this works is that rounds of dialogue are held with bidders, clarifying and honing ideas, until the best fit to achieve our required outcomes is arrived at.  This iterative approach represents best practice in procurement, as there is flexibility to shape services throughout the process, through patient and public engagement and through ideas from potential providers and commissioners, before finalising service specifications.

There are a range of ways in which you can approach this, but for us in practice this has meant that once the initial prequalification* stage was passed by potential providers we met with them one at a time to discuss what we wanted for our population and what they could potentially provide; formal written bids were then submitted, which were scored and any providers who didn’t meet a necessary minimum score dropped out.  The next round of ‘dialogue’ is currently in progress, but to a more detailed level, including providers sharing proposed service specifications.  Further formal written ‘bid’ documents will then be submitted and scored. Following a final executive-level panel meeting between bidders and commissioners, a proposal will be made to the Board to agree a preferred bidder and then contract negotiation starts.  We report regularly to our Board to update on progress with this procurement.  The latest Board paper summarising progress to date is here.

This whole process may all sound a bit complicated, and it is!  There is a lot at stake, with many tens of millions of pounds of public money involved in the potential contracts for these services and more importantly the potential benefit to the people of Luton and their health.  One significant thing that we have learned so far from the process is that it is definitely worth all the complexity and hard work.  We intend on getting really high quality services as a result, which are focussed on meeting the needs and achieving positive outcomes for our local population.  We have particularly valued the involvement of members of the public throughout the whole process and the contribution they are making to this being successful.  An element of the public involvement we have run was our ‘Big Conversation’.  The whole approach we’ve taken to involving the public in this procurement may be a subject I blog about in the future.

The procurement continues and I’ll provide an update in a future blog.

(*Preliminary stage in a bidding process where it is determined if a provider has the requisite resources and experience to provide the service as required.)

Week 11: Celebrate the 6Cs on International Nurses/Midwife Day

For 2014’s International Day of the Midwife and International Nurses’ Day on 5 and 12 May I would like to propose that we add some celebration to the 6Cs.

In our very busy personal and professional lives there is often little boundary between the two!  We seldom take time to appreciate what we have, where we’ve come from and the wonderful profession that we share.

I am proud to be a nurse and have been extremely fortunate in my nursing career so far to have worked with some amazing nurses and midwives from whom I have learned so much.  I have also been given fantastic opportunities to experience and do things I never would have achieved on my own or in many other professions.

It is important that we celebrate nurses, midwives and all those who choose to care for others for a living.  As a profession we are often negatively stereotyped and very quick to be self-critical and don’t always do as much as we can to promote the many positives of what we contribute to society.  Sandy Summers’ series in The Nursing Times challenges some of these negative stereotypes and proposes further ways to break these down.  The RCN’s ‘This is NursingCampaign’ also goes some way to better describe our role to the public.

We must eliminate the use of negative language to describe our profession and our place within it.  A particular pet hate of mine is the use of the word “just”, as in the phrase “...just a nurse...” or “...just a student...” and certainly never both together!  This devalues what we do, the role we play individually and as part of a team wherever we work. So let’s commit to never using these terms ourselves and challenging them when we hear others say them.

These, along with further efforts, are needed to ensure that there is more celebration of nurses and midwives.  In the UK, the final (61^st) requirement of the Nursing & Midwifery Council Code for nurses and midwives is:

“61. You must uphold the reputation of your profession at all times”

This requirement of all registered nurses and midwives is usually viewed as “don’t do things that will bring the profession into disrepute”; however, whilst this is an important interpretation, I think it should be seen as an active requirement to positively celebrate and promote the profession... and perhaps this should become the first requirement of the Code, not the last!

So, let’s take these two days on  5 and 12 May 2014 as an opportunity to celebrate nurses and midwives, to celebrate all that we do for people and to celebrate what wonderful people nurses and midwives are!

This doesn’t have to be sycophantic or arrogant; we should never be embarrassed to say who we are and what we do.  Whenever I meet someone new and am asked what I do for a living, I always say first “I’m a nurse”.

So nurses and midwives everywhere, celebrate your values that make you who you are, be sure to be true to them and positively uphold the reputation of the profession.

David Foord, Nurse & Director of Quality for NHS Luton Clinical Commissioning Group

You can follow David on Twitter: @DGFoord  connect with him via Linked In and read his weekly blog here.

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…