In part two of our series looking at CQC inspection key lines of enquiries (KLOEs), we looked generally at the KLOE that deals with Practice Leadership. While the PM may not necessarily be the leader, there is a great deal of leadership work that falls to most of us. Casting minds back to 2004 and the “new contract” that was initially proposed, a large section of the QOF measured management and leadership issues, but these were all removed before the final implementation – only to reappear some years later as part of the Fundamental Standards on which KLOEs are based.  There are three main themes for Practice Managers in this KLOE:

Strategy and planning

Clear and inclusive processes that promote practice values and clarity of purpose within the local health economy are all part of this aspect of Well-led. There are various aspects interspersed throughout the list of characteristics that inspectors are looking for and it’s perhaps no coincidence that the first couple of prompts require the practice to have leaders who are visible and approachable, and for the practice to have a succession plan to ensure it develops the leaders of the future. Most PMs will raise an eyebrow or two at this and find their own experience rather different, but it does seem the days of the senior partner being the actual leader by taking their turn is numbered.

Proceeding onwards through the KLOE, the emphasis is on having plans and long-term strategies that are there to deliver quality care to patients that can be sustained in terms both of staffing and finance. The plans also must be clear about who does what and when so responsibilities need to be clear. The plans also should be drawn up in an open and honest manner using input from all of the stakeholders of the organisation (remembering that staff and patients are both in that category) and that the culture of the practice fits what the plans are trying to achieve.

PMs need to be able to drive this agenda in the absence of anyone skilled enough or prepared to do it. Does the practice have an annual planning day where everyone has the chance to feed into the outcome? Accepting that partnerships are owned by the partners and some run by a board as part of a larger organisation, it does not mean that the executive level has all the ideas. While they may have away-days to firm up strategy, taking notice of feedback from staff, patients, secondary care, the CCG and anyone else with a stake in the business needs to be evidenced.

New additions in this area include the requirement that practice plans must align themselves to the wider area plans and especially be relevant to what the local population needs (and please do note the “needs”, not the “wants” – a much wider remit than just doing what the PPG want and which encompasses both Health and Social Care). The new requirements take a pretty big step forward in also requiring any service or efficiency changes not to have a negative impact on service delivery, to be monitored and assessed for sustainability and also to highlight where “financial pressures have compromised care”. Take a look at the Practice Index Business Development Plan and Business Continuity Policy [PLUS] for guidance and inspiration.

Involving and working through people

Looking at whether the leader(s) of the practice are visible and approachable has been mentioned, but the issue which carries a `barb` is still in there – namely that actions inconsistent with the values and vision of the practice are addressed “regardless of seniority”.

It, therefore, follows that everyone must know the values of the practice and where its` strategic direction might be. It does seem to follow that involvement in drawing up the plans will also ensure staff, in particular, are aware of them when asked (you would be surprised how many don`t know this on an Inspection) and also what the underlying values of the practice are. The challenge for the larger organisations is how to operate on a corporate basis but deliver services to diverse localities and still follow the KLOEs. Practice Index has produced a Vision, Values and Accountability guidance document [PLUS].

The KLOE goes on to say that staff must feel supported and proud to be in the practice which has a culture of care. This includes care, not just for patients, but for the staff, their development and for the suggestions that they may have to offer, which means that staff involvement across all the roles in all meetings is indicated. SEAs and Complaint meetings (even reception staff when relating to clinical issues), input to business meetings, taking and receiving suggestions to improve the service and listening to their worries are all important. Look at the SEA Policy [PLUS] for detailed guidance and also the Complaint Procedures Policy [PLUS].

The Patient Group, Practice Pharmacist, Community staff and a range of external people that have some interest in services are also all potential participants in meetings. Importantly, their contribution, whether present in person or through some other means should be recorded in the minutes. Practice Index PLUS has the following PPG resources: PPG Presentation, PPG Policy and PPG GDPR email.

Don’t forget the contribution made by locums. Conversely, are you ensuring locums get to know the plans and issues the practice have and where they need to play their part?

The management process

Managers monitor the practice performance, or at least they should do. PMs need to be aware of the external environment, up and coming issues, the direction the local Health economy is heading as much as you have your finger on the pulse of practice performance. The practice needs to have the data to check progress against the plans and someone (invariably the PM) to spot problems before they become a drama, assess the performance of staff, audit operational and financial issues as part of good governance and ensure that all lessons learned are remembered and checked back on. The only problem, however, is that when you are up to your neck in alligators it’s difficult to remember the initial objective was to drain the swamp!

The professional practice manager will have processes in place that manage risk and performance (won`t they?) that should make all of these tasks routine and that is what CQC will look for. Are there clear performance measures, checked and actioned when needed, are the changes monitored and issues re-visited regularly? Do you document them to both provide evidence for your Inspection and also to defend the practice against unsubstantiated complaints or legal action? Do you lead by example in ensuring the practice processes do not put staff at risk?

All of these are component parts of Well-led and if you can extract yourself from the swamp to do them you may find that you will need to promote leadership principles to those who really should be the leaders in the practice.

The KLOE does ask you to look outside the practice and engage with everyone who can help to shape practice strategy and provide a service that fits local, regional and national systems. In one area at least, practices are experimenting with vertical integration – reducing the lines between primary and secondary care – and that, of course, will have an impact on what the practice strategy and vision will be. I bet it takes the managers to make it work and it’s a clear example of practices not allowing themselves to stand still, but instead, innovate and co-operate with others to provide a service that is intended to improve the way the system works. Again, this is an issue that the KLOE covers.

Well-led is just one of those KLOES which everyone thinks they know about and probably they do, but not always on a conscious level. Well-led is not always evidenced through direct inspection but is a feeling that you get when you are in the practice and what management theorists call the `paradigm` (the way things are done here) can become very clear. The inspection team start to hear the way the staff, partners and the manager speak and the way they describe how the practice runs.  That leads on to picking up the training that is given or funded to enable staff to develop and learn, the minutes of meetings make reference to suggestions coming from all levels of staff, the attendance list for meetings has people from across the board and, when speaking to staff and patients, you can tell if they feel valued for their opinions and supported in the contributions they can make. Get that right and you’ll be on the way to being well-led.

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

Helpful document for your CQC inspection: CQC guidance

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