Leadership, culture and the CQC

The CQC has just published its latest State of Care report and it makes interesting reading.  In particular, it raises the question of leadership in relation to quality and culture, and how there seems to be a positive correlation between the ratings for the whole service and the ‘well-led’ rating.  Although the report covers all areas of health and social care that the CQC regulates (which is just about everything nowadays), in the this post I want to focus particularly on the adult social care sector.

Before looking at the question of leadership in particular, it’s worth looking at some of the headlines figures for adult social care in general.  Up to 31 May 2015 the CQC had inspected and rated 17% of all adult social care services under its new inspection framework.  Of these, 59% were rated as ‘good’ or ‘outstanding’, 33% as ‘requires improvement’, and 7% as ‘inadequate’.  Nursing home had the largest proportion of ‘inadequate’ ratings (10%).  Safety was the biggest concern in all services (including hospitals) with 10% being rated as ‘inadequate’.  Leadership was also significant concern, with 8% of services being rated ‘inadequate’ for this domain.

The CQC also commented on the future challenges faced by the adult social care sector, and noted that there was limited scope for further savings.  At the same time, the new eligibility criteria in the Care Act 2014 was reducing commissioners’ ability to limit access.  This means that providers and commissioners are facing a ‘perfect storm’ of restricted funding and growing demand.  Providers are already struggling to balance the need for maintaining financial viability with the need to maintain quality of care and this is only likely to get worse in the future. The report quotes the King’s Fund:

In our view it is not credible to maintain that current standards of care can be sustained (let alone improved) without the funding needed to deliver this.

When it comes to the question of leadership the report notes that 94% of (all) services with a ‘good’ or ‘outstanding’ overall rating were also rated as ‘good’ or ‘outstanding’ in the ‘well-led. domain.   Conversely, 84% of ‘inadequate’ services were also rated ‘inadequate’ for ‘well- led’.  The report went on to comment:

This (the leadership ratings) suggests that the way in which an organisation is led, and the culture and values that influence it as a result, have a huge and far- reaching impact on the overall quality of care that people receive. Good leadership, at all levels of an organisation, is required to deliver care that is consistently safe, effective, caring and responsive.

The report identified five critical aspects of good leadership:

  1. Effective engagement and communication with staff and people using service
  2. The skills, experience and visibility of management
  3. A strong and positive organisational culture
  4. Learning when things go wrong
  5. Governance processes to support openness and transparency

Even though the report highlights a strong and positive culture as one aspect of strong leadership, I would argue that all five of these aspects relate in some way to the culture of the service.  The report emphasises the need for a:

…positive organisational culture that is open and transparent, and a culture where the vision and values are embedded and really understood by staff across the service.

It also states that a culture of bullying or staff feeling unable to speak up is often a problem in services rated as ‘inadequate’ for leadership or safety.

So what are we to make of these findings, and particularly in relation to the question of culture and leadership?   There seems to be something of a ‘received wisdom’ in many management and organisational studies circles that it is leaders (by which they mean those in senior management or equivalent positions) who both shape and manage the culture of a particular organisation or service.  This is certainly the view of people like Edgar Schein, a major theorist of organisational culture, who writes about the importance of ‘espoused values’, which are circulated throughout the organisation and which emanate from senior managers.

The general idea is that leaders ‘set’ the culture of the whole organisation and ensure that everyone within the organisation adheres to its values and basic assumptions, i.e. the values and basic assumptions of the leadership.  The problem is that this is based on a completely false conception of organisational culture.  Or, to be more precise, it is based on a very narrow and partisan conception of culture, i.e. that held by senior managers. 

As I discussed in my posting on organisational culture, not only is ‘culture’ very difficult to define, it is also extremely complex.  Furthermore, there is not one culture within a particular organisation but many.  However, rather than talking about ‘sub-cultures’, which many theorists do, I prefer the term ‘social worlds’.  ‘Sub-culture’ implies that there is one culture that it then ‘divided’ into a number of ‘sub-sets’; whereas the concept of social worlds recognises that there are a number of different cultures which may or may not relate to one another.  Furthermore, depending which ‘world’ you live in, you will have a completely different idea of what ‘the organisation’ or ‘service’ is to start with. 

For example, staff within a care service tend to define ‘the service’ or ‘the organisation’ in terms of their direct relationships with service users, other staff members and their line manager.  Service users also tend to view ‘the service’ in terms of their immediate personal relationships with staff and other service users. Whereas senior managers, especially in a large care organisation with multiple services, tend to have a more ‘global’ but at the same time more abstract view of ‘the organisation’, and think of it more in terms of organisational charts, spreadsheets and so on.  Front line managers are often in the most difficult position of having to ‘mediate’ between the senior management ‘version’ of the service and that of the staff and service users.

But why does this matter?  To start with, the idea of multiple social worlds helps explain why so many change management initiatives fail – something in the region of 70% or more.  Often it’s because those initiating the changes are senior managers, who feel part of their role is to initiate change management programmes.  Unfortunately, other people in the organisation may have a very different idea of about what needs changing, especially if change is likely to threaten their vested interests.  And at this point it’s worth remembering that different people, different ‘stakeholders’, have a different idea of what ‘the organisation’ is in the first place.

The reason I’m focusing on the question of change management is that CQC reports, and particularly poor ones, are often the catalyst for change within a particular service.  And the responsibility for initiating and managing such change sits with the leadership of the service.  The problem is, unless the leadership recognise the complexity of any change initiative and the fact it’s not something they can (successfully) ‘impose’ on the rest of the service, then the chances of them implementing the necessary changes are minimal. 

Instead, I would argue that although leaders do not define the culture of the service they can certainly influence it, and have a responsibility for trying to understand it.  This is not so much about attempting to ‘manage’ culture in terms of defining or controlling it, but rather having a clear appreciation of its nature, and particularly of its complexity.  With regards to the concept of social worlds, leaders can see their role as ‘managing’ the tensions and conflicts between these different worlds and trying to facilitate dialogue and understanding between them. 

Essentially, this means that leaders and managers (who may not always be the same people) need to stop worrying about being in control all the time.  Rather, they can start to see their role as steering the organisation or service in a particular direction, whilst accepting that ‘the organisation’ is, in many ways, a fiction.  Rather, it is a number of competing interests which need to be harnessed in order to achieve a particular set of outcomes.