Leadership is defined in many ways. The Oxford Dictionary is little help as it merely says, “The action of leading a group of people or an organisation,” while Forbes defines it as being, “a process of social influence, which maximises the efforts of others, towards the achievement of a goal”. One of the most influential writers on business and management, Peter Drucker, felt that leadership encompassed many different areas such as ethics, integrity, motivation, direction and perhaps the most important – setting the tone for how the organisation is viewed – from both inside and outside.

With all of this in mind, how can the practice demonstrate `well-led` to the CQC inspection team? A good place to start is to take an in-depth look at the well-led KLOE to get some idea of what is being looked for. Right at the start, it indicates that well-led covers the ‘leadership, management and governance of the practice so that it delivers high-quality patient-centred care, gives support to learning and innovation, and runs in an open and fair manner.

The KLOE documentation goes on to establish eight different tests of whether a practice enjoys good (or outstanding) leadership, which briefly are:

• Do the leaders have the right skills and proper understanding of the business to make the best long-term decisions and include as many people as possible in shaping them?
• Have they a clear vision to provide long-term quality care and is delivery of that vision properly planned? Do those plans fit patient needs and dove-tail with local social and health plans?
• Is the whole practice singing from the same hymn sheet, are they well supported, equally respected, motivated and willing participants?
• Is there good governance? For example, are there clear lines of management and responsibility for how things work?
• Is the practice aware of what it actually does, aware of what or who may not be working well and the risks to staff and patients, both financial and operational?
• Does the practice monitor performance (including data security) and use that information to improve, rather than rest on its laurels?
• Is the practice using contributions from everyone inside and outside the organisation to support what it does? In management-speak, does it consult with and listen to all of its stakeholders?
• Is it a learning organisation at all levels?

You might now be asking ‘how do I demonstrate we are well-led’? It’s worth saying that this is probably the hardest question to answer in every KLOE. One way to identify what makes good leaders is to illustrate some poor leadership behaviours (and then try to avoid them happening in your practice). It’s also worth adding that sometimes the leaders are not always the people you might think.

Leadership may be provided by another partner or the practice manager who drives the organisation forward and brings everyone together to do so. There may even be more than one leader. But the question here is whether they work together collaboratively or in competition, which of course is destructive. Inspections can often recognise some of the following leadership styles in varying degrees, but hopefully not all in the same person or in the same practice.

The Authoritarian. Might get things done but are they the right things? Does this behaviour motivate the staff to go that bit further for the patients, or just perform exactly as they are told without any opportunity to contribute good ideas? Are they simply regarded as a bully who staff are afraid of crossing, so they and patients do not involve themselves in progress? In many cases, should the Authoritarian drop themselves into trouble you can hear everyone taking a sharp step backwards from offering any sort of assistance.

The Indecisive Wuss. Feeble and easily pushed in every direction by everyone who is stronger-willed. A person regarded by everyone as weak, ineffectual, or overly fearful of either offending everyone or making any sort of decision. They let the practice drift without clarity of purpose or strategy, never try to improve it and often only listen to the person who shouts the loudest – whether it is a receptionist, nurse or a bombastic patient.

Nursing staff put themselves on the training courses they want and not on those they need, salaried GPs work the sessions that suit themselves and not when patient demand is high or they let non-clinical staff take an `early dart` but no-one tells the practice manager and reception is under-staffed with patients complaining all the time.

The Disinterested. Typically, these leaders will say… “Do whatever you think is best”, “Don`t bother me with that now – perhaps we`ll look at it some other time” or even “Roll on retirement”. The staff response to these `leaders` is just to not bother to be enthusiastic because it gets them nowhere. The same significant events happen repeatedly, or the same complaints recur, but they are shrugged off or no-one bothers to check that changes are actioned or learning applied. It is easier to make an excuse than to investigate, learn and monitor changes.

The Insecure. Typically a micro-manager who interferes with everything people do because they want it done their way. It requires the leader to actually have the skills necessary to know how every job in the team should be done, from how to apply a dressing or take an ECG through to how to operate the phone system or run the payroll. It does raise the question whether the `insecure leader` fears being shown up, despite the fact that trusting staff to work well is important as it demonstrates they are valued and respected. Poor leaders might play favourites with staff, obviously choosing one staff member to receive special treatment. Employee conflicts can be frightening for the leadership-challenged who don’t have the skills necessary to mediate and resolve communication problems between staff members.

The Non-Communicator. Having neither clarity of purpose, nor the ability to communicate it, are related in as much as no-one knows what to do or where they are heading. That makes for poor care and increased risk of harm to patients. Failing to make expectations and directions clear can frustrate staff and impacts on their ability to successfully complete a task. Poor leaders might not tell employees when a project is due or might suddenly move up the due date. Project details can be vague, making it difficult for employees to guess what factors the supervisor considers important. If a project involves participation from more than one employee, a poor leader might not explain who is responsible for performing each part of the project.

The Ostrich. There is a saying that `failing to plan is planning to fail`. One of the main changes in the well-led KLOE for 2018 is a re-emphasis on planning, both in the practice and also by participating in and having regard for the wider health and social care economy. The non-planner can usually be recognised by regarding everything as being resolved by using common sense – the flaw being that common sense is not necessarily common! In not having properly-prepared plans, the practice cannot show to anyone that it has recognised risks – both financial and safety – to sustainable care for its patients. It cannot show that it regularly re-visits or details its operational and long-term strategy. Of course, thinking about the Ostrich, which part of its anatomy is never covered?

However, it is not just traits of leadership that need to be considered. Practice Managers by virtue of their title are classed as managers but they do need to be leaders too. It was Koontz (1964) who said that individuals cannot have the traits of both a leader and manager, as the distinction between the two roles is so high, but it could be argued that practice managers do in fact need the traits of both if they are to succeed. So just what skills are needed?

Well, let’s use the acronym PODSCORB (Gulick, 1973) to illustrate management skills: Planning, Organising, Directing, Staffing, Coordinating, Reporting, Budgeting. Compare this to the leadership skills suggested by Kotter (1990), who states leaders: Give direction, communicate direction, motivation, provide inspiration and understand the needs, values and emotions of the employees.

It is evident from the above, that practice managers need to combine the skills of both leaders and managers effectively to ensure their practices are well-led, which is such a significant element of the role.

In the next article, we look at some of the more specific sections under Well-led and concentrate on the positives, especially those where the practice manager has a greater part to play.

Catch up with the rest of “The inspection insider” series here.

Helpful document for your CQC inspection: CQC guidance