CQC's State of Care is both reassuring and disturbing

The Care Quality Commission’s State of Care report has both reassuring and disturbing messages: reassuring in that the majority of services are good, but disturbing in that there is significant variation in quality and particularly safety.

‘We must improve leadership across the sector’

The report singles out leadership as fundamental to this variation – inadequate leadership is linked to inadequate care, while good and outstanding leadership create the conditions for high quality, continually improving and compassionate care.

The implication is that we must improve leadership across the sector. This means that we must work hard to raise leadership standards overall and to reduce variation in leadership quality. How is this to be done?

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Make do won’t do

A recent King’s Fund report revealed that:

• almost one-third of trusts had at least one board level vacancy or an interim executive board member;
• most of the vacancies were for finance director roles while nursing director posts were vacant for the longest;
• 9 per cent of all trusts had no substantive finance director;
• 12 per cent had no substantive chief operating officer;
• 16 per cent of mental health trusts had no substantive director of nursing and 14 per cent had no substantive finance director; and
• 16 per cent of community trusts had no substantive chief executive officer.

This reflects significant and deep seated problems with the culture and environment in which NHS leaders operate in. However, NHS boards also have a major role to play and must approach leadership with the same determined, intelligent and strategic approach they would bring to any other key area like quality of care, financial performance or preparing for inspections.

Ad hoc, make do and get by approaches to leadership are unacceptable in an industry concerned with saving lives.

Scrabbling around to find people to fill leadership positions is not a long term leadership strategy. Sending leaders and leaders-in-waiting on inspiring leadership courses will not be effective either if, on returning to their organisations, their attempts to implement new found knowledge are frustrated by the system.

Beyond governance

Good leadership goes beyond governance. The CQC well led domain, developed with help from the King’s Fund, covers five critical aspects of good leadership, including culture and engaging staff. These aspects require a strategic approach to leadership where trusts identify the challenge first.

What is the current culture of the organisation and what needs to change? The extent to which there is a shared vision and values? The effectiveness of performance management? Staff support, strain and bullying? The quality and extensiveness of team and inter-team working (both within and across organisational boundaries)? Or the ability as an organisation to learn, improve and innovate?

‘There’s a need for collective leadership rather than the controlling leadership endemic in the NHS’

And what of the leadership? Is there a consistent leadership style that supports staff to deliver high quality, continually improving and compassionate care? Are leaders empowering, engaging, listening, compassionate, open and authentic in their dealings with staff? Are the key leadership positions filled by people with the knowledge, skills, values and attitudes necessary for those roles?

And is there good bench strength – a pipeline of leaders-in-waiting, ready to step into roles as existing leaders move on?

Reports repeatedly identify the need for collective leadership rather than the dominant, hierarchical and controlling leadership which is endemic in NHS organisations. However, the latest NHS national staff survey revealed that:

• only 31 per cent of staff felt that their managers involve them in important decisions;
• just over one-third of staff felt that communication between managers and staff is effective (37 per cent); and
• less than a third (29 per cent) reported that senior managers act on feedback from staff.

Sustained culture change

One of the areas State of Care identifies where organisations should focus is increasing staff engagement to build shared ownership of quality and safety.

Collective leadership epitomises this shared ownership:

• where all staff feel motivated and empowered to play leadership roles when necessary;
• where there is shared leadership in all teams, such that the team leader facilitates rather than directs, and empowers rather than controls;
• where leadership is characterised by coordination across boundaries, with leaders prioritising patient care overall, not just their area of immediate responsibility; and
• where leaders’ dominant approach is encouraging and enabling the contribution, accountability, engagement and responsibility of all.

Developing an effective leadership strategy requires the board to mandate (among others) the human resources, quality and organisational development functions to work together and with all staff to develop an integrated and coherent strategy that will deliver the leadership the organisation needs. It involves attracting, selecting and developing leaders for all key positions in ways that reinforce the desired culture of high quality and safe care.

‘Culture change requires long term stable leadership’

And the strategy must be implemented and sustained over the years that follow. This might be five years or more, but that is the timescale of sustained culture change. Culture change requires long term stable leadership, creating a firm foundation with consistent messages and integrated processes across the organisation that deliver the cultural elements we know are needed.

And the regulatory agencies must support and enable organisations on this journey, reinforcing the value of pursuing long term strategies to achieve sustainable improvement in care for the people of our communities.

Michael West is head of thought leadership for the King’s Fund