1. Inclusive Leadership: evidence and impact
Professor Ursula Gallagher
Deputy Chief Inspector
13th July 2016

2. Why leadership matters?
Since 2013 CQC inspecting using new methodology
Areas inspected
ASC
PMS inc C, H&J, ID, Dentists, OOHs/111, as well as GPs
Hospitals inc MH, Community Services and IH
Inspect against 5 Domains
Safe
Effective
Caring
Responsive
Well-led
What are we learning?

3. Ratings summary: key questions
The purpose of this slide is to show how the well led key question compares with the other 4 in each of the main rated sectors.

4. Ratings summary: well-led
The purpose of this slide is to show how well-led varies by sector, but also by level of rating within the organisation – so for Acute trusts which receive a well led rating at provider level and also at hospital level and core service level. Potentially the differences may show that service level leadership is stronger than board level, although the differences will also partly be due to the process of aggregating ratings, which magnifies the poorer ratings.

5. NHS Staff Survey
These three key findings in the NHS staff survey give a useful indication of staff confidence in the leadership of the trust. All have been improving steadily in recent years.
Source: NHS Staff Survey

6. NHS Staff Survey and ratings
The purpose of this slide is to show that better rated NHS acute trusts are associated with staff being more likely to recommend the organisation as a place to work or receive treatment.
Scale scores calculations:
Questions score responses from 1 to 5 with 5 being strongly agree and 1 being strongly disagree, and average is then calculated.
For instance, if a respondent were to score 2, 3 and 5 for the statements then their average score would be ( ) / 3 = 3.33.
Source: NHS Staff Survey 2015, CQC ratings for NHS acute non-specialist trusts

7. NHS Staff Survey,
Change in score from 2014 to 2015, staff recommendation of the organisation as a place to work or receive treatment (trusts rated inadequate)
The purpose of this slide is to show that even among trusts rated inadequate the staff recommendation question has tended to improve from 2014 to 2015, and this is also the case with RI and Good on the next slide. There are too few outstanding trusts to make meaningful chart.

8. NHS Staff Survey,
Change in score from 2014 to 2015, staff recommendation of the organisation as a place to work or receive treatment (trusts rated requires improvement and good)

9. NHS Staff Survey Workplace Race Equality Standards: how we will be using this to help assess NHS trusts
Notes from Jon Shelton:
With regards to Workforce Race Equality Standard (WRES), we have produced analysis of the four NHS staff survey questions related to acute trusts. These statistical analyses have been used in supporting the pilots of WRES data under the Well Led domain along with further briefings produced by colleagues in NHS London.
We will be including analysis of the NHS Staff Survey questions related to the WRES for all inspections, focussing not just on the results for the four relevant questions, but on the sampling method used (which can just be a basic sample and therefore lead to only a small number of BME respondents) and the response rate. The focus on using these data is firstly, does the trust understand any issues relating to WRES at their trust and secondly, what are they doing to try and improve experiences for all staff, especially for those that report a worse experience. Under the acute hospitals inspection process, this is looked at under the well-led question at trust level. Similarly, WRES is being inspected under the well-led question for MH and Ambulances, with results from the NHS Staff survey supporting the inspection process.
The slide linked below is the template we will be using for acute trusts from August onwards.  The main focus is on the difference in results between White and BME staff at a trust. For trusts that have less than 50 BME respondents and didn’t undertake a census, we don’t produce statistical analysis of the results as the expected variation is great. For these trusts we focus on how the trusts understands the experiences of BME staff. The analysis also compares the results for each question for the BME staff compared to BME results for acute trusts in England and BME staff against overall BME responses from acute trusts in England.
SOURCE: NHS Staff Survey 2015 Key Findings (

10. Improving leadership: qualitative analysis
Staff survey and Patient Survey – key
Characteristics
Top leadership highly visible
High value placed on engaging and getting feedback esp structures to engage H2R groups
Investment in leadership education and development
Good leadership is strongly associated with positive change. This is about setting the organisational culture and senior staff being in touch with issues, problems and concerns with provision and at anticipating, spotting and responding to them.
These slides are based on a summary of work undertaken by the Qualitative Team for the State of Care report which combined focus groups with inspectors with analysis of a sample of our published inspection reports.

11. Improving leadership: qualitative analysis
Adult social care
An open culture and a willingness to change are important factors in bringing about positive change.
Improvements included improved staffing levels, staff being in better control of their workloads and improved provision of relevant staff training. They also included managers at regional and location level using systems and processes to improve their oversight of the quality of care provided, and taking charge of ineffective admissions processes.
Inspectors also commented – particularly in respect of large corporate providers – that regional-level management could be in a good position to spot early warning signs of a service beginning to decline. Inspectors were of the view that, in addition to the importance of there being good management in place at a location level, this ‘oversight’ was an important factor in ensuring positive changes were identified and implemented such that overall provision could improve.

12. Improving leadership: qualitative analysis
Acute
As well as engaging with staff and other providers, there was also evidence of services making improvements to the way in which they engaged with and sought feedback from patients and members of the public with the intention of using this to make improvements to the service.
Mental health
As in the case of acute providers, changes to management at a high level (while retaining stability at a ward level) was mentioned by inspectors as a key way in which improvements to the well-led domain had been made following a less good initial inspection.
In addition, the importance of senior leaders making themselves more available (for example by a “big breakfast” informal meeting with staff and the chief executive) was also stressed.
Other examples within the well-led domain included improvements to staff recruitment processes (such as taking better account of the fit and proper person requirement and DBS (disclosure and barring service) checking), and improvements to staff morale.

13. Improving leadership: qualitative analysis
Primary medical services
Governance and governance frameworks were a key area of improvement identified in inspection reports. Examples included introducing a new “electronic management workflow system [that] would provide an automatic audit trail for all documents read and reviewed by staff” (Constable Country Rural Medical Practice), the implementation of comprehensive assurance and audit systems, and putting in place a compliance officer.
Engagement with people and staff was also highlighted as an area of improvement. The introduction of Patient Participation Groups and the way in which practices interacted with them, was a particular aspect of this aspect of improving provision.
The development of organisational cultures of continuous learning, improvement and innovation, and of having a clear vision, strategy and values policy were other factors which contributed to good ratings in PMS follow-up inspection reports.

14. Conclusions and next steps
The quality of Leadership does impact patient care
In all sectors
Great leadership is not about ‘heros and heroines’!
Great leadership engages staff and patient
Great Leadership invests in people but also systems
Our new strategy will continue to focus on the assessment of the well led domain
Developing a shared view of quality