If I knew then what I know now

Sir David Behan, outgoing Chief Executive of the Care Quality Commission, shares his reflections on leadership from the past 40 years

As I have approached the end of my time at the Care Quality Commission (CQC), the majority of the speeches I have delivered to leaders in health and social care over the past weeks have focused on my personal reflections on leadership over the last 40 years. A number of people suggested that I should share my thoughts more widely.

I learned of the acronym VUCA — volatility, uncertainty, complexity and ambiguity — from a colleague in CQC. The term is used to describe the context in which we operate. While it can be applied to many situations, I’m sure many would agree that it describes the extraordinary demands on those working across health and social care. It certainly captures the context in which I’ve operated over recent years, and I hope to offer some insight into how I’ve tackled these challenges myself.

Purpose

Over my career, I have learned the importance of being oneself and so being clear why you are here. Ask, “what is your personal purpose?” not “what is your job”. There is a sweet spot for us all where we’re able to secure alignment between our own personal purpose and values, and those of the organisations we work for. This — probably more than anything else — has helped me to navigate a world characterised by VUCA.

Over my career, I have learned the importance of being oneself and so being clear why you are here

For me, my purpose was to make a contribution to a more socially-just society; to make a difference. I found that passion while still at school in 1972, through voluntary work with single homeless people. This experience led me to think quite broadly about social justice, about equality and inclusion and the role of the state in supporting those who required help. I wanted to do a job which basically ‘made a difference’. That led me into a career in social work. My motivation has been to want to make a difference, and I feel fortunate to have had roles through my career that, in my own mind, have all been focused on creating a more socially just society. When things have got really tough, such as when as a Director of Social Services a child on the child protection register dies; or in some of the challenges in the early days of CQC, having this clarity of personal purpose has been my guiding star.

This is a similar point to the apocryphal anecdote of the US President at NASA when in answer to his question, “What is your role?” the caretaker replied: “To put a man on the moon, Mr President”.

Having asked about your own purpose and why you are there, the next step is to consider why is your organisation there, and ask: “What is its purpose?”

I have been leading organisations for over 24 years. In particular, over the past 12 years or so I have learned the importance of being clear about the purpose of the organisation I’m leading. By this I don’t mean whether there is a vision or a legal definition, but whether there is a statement of purpose that guides your actions and the actions of all staff in the organisation. At CQC we have a simple but clear statement of purpose:

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.”

In our last staff survey, 94% of colleagues supported this statement; they connect with it emotionally and psychologically.

But, does the thinking on purpose extend to the systems we work in? The evidence from our local system reviews is that clarity of purpose is essential for system success. As services move to responding to people of all ages with complex, co-morbid conditions who require more collaboration between organisations and staff, the question becomes: “Is there a clear shared statement of purpose for this system, which guides the actions of people who work within the system?”

Any organisation or system which is not clear about its purpose will fail.

Any individual who isn’t clear about their purpose will be dissatisfied, probably anxious and unhappy, and they are also likely to fail.

In many respects the work I undertook in 2012/13 on developing and agreeing the CQC statement of purpose was the single most important initiative in my time at CQC. It has been the foundation on which so much other work has been built.

Values and behaviours

Personal and organisational values influence and shape the way people in an organisation behave with each other. When an organisation develops a statement of values it is in effect beginning to address the question of ‘what’ type of organisation it wants to be, and ‘how’ it wants to be with others.

If purpose is a statement of ‘why’, then values are a statement of ‘how’. It is the behaviour which demonstrates those values which is critical in any organisation. My own values are of fairness and integrity: they inform my own purpose but also my behaviour. Leaders are often judged not by what they say but by what they do and how they do it. People look for leaders who are authentic, who do what they say and who align their values with their behaviour.

Again I have been fortunate in my own values aligning with those of the organisations I have worked for.

Staff engagement

Successful organisations deliver their purpose and their tasks, but they also engage their workforce. They attend to the physical, emotional and psychological wellbeing of their people.

In the healthcare world, research at The King’s Fund, conducted by Michael West and Jeremy Dawson, looks at employee engagement and NHS performance. The paper summarises evidence through national NHS Staff Surveys and highlights outcome measures such as turnover, patient satisfaction and mortality. The conclusion gives a clear message about the importance of staff engagement: the more engaged staff members are, the better the outcomes for patients and the organisation.

Successful organisations attend to the physical, emotional and psychological wellbeing of their people

The sense of empowered teamwork has echoed throughout our Driving Improvement series. These case studies highlight how NHS, mental health, adult social care and general practice providers have improved their rating, demonstrating that clarity of purpose is something we should all tap into when leading and being part of a team. This comes through in many of the case studies in the series, but is summed up particularly well by Kevin McGee, Chief Executive of East Lancashire Hospitals Trust, when he said that improvement “starts and ends with staff engagement”.

In my position as Chief Executive of CQC, I think that my most important performance indicator is the staff engagement index score.

Why? Because engagement of the workforce is the single most critical component of successful organisations and successful leaders. I always thought I was good at ‘walking the job’. What I have come to learn is the importance of actively listening to staff: hearing from them what is and isn’t working. We need to ask staff how they can be supported to be the best they can be and what barriers to this need to be removed, and find out whether we can incentivise, encourage and facilitate them.

I came to this realisation in my time in the Department of Health. Up to this point, when I walked into the job I think I was on ‘broadcast’ rather than ‘receive’, or at least I was assessing whether the latest initiative was being delivered. Actively listening, and I mean really listening, rather than waiting to speak, is a key skill of leadership. I believe emotional intelligence, not just academic intelligence, is an essential characteristic of successful leaders: the ability to be aware of oneself, of others and to self-regulate, and, critically, to be able to see and understand the world from the perspective of others.

Engagement of the workforce is the single most critical component of successful organisations and successful leaders

I believe leadership through position and hierarchy is at its limit; a more distributed, more compassionate approach to leadership is key to the future; a leadership that engages with the energy and passion of its staff. This approach to leadership connects with people’s emotions as well as their thoughts.

Of course, it’s not just about engaging with staff: engaging with people who use services is equally important. All of the above applies to the importance of engaging with those people who use services, where the skill of actively listening and the exercise of emotional intelligence are critical.

A culture of learning, openness and transparency

One of the greatest changes during my 40 years in public service has been the rising importance of the ‘culture’ of the organisations and systems we work in.

It was Sir Robert Francis’ inquiry report on Mid Staffordshire that really opened my eyes to this issue. When studying social psychology, I had read Erving Goffman’s classic text Asylum and thought I understood how organisations impact on people who use services, but it was Sir Robert’s report which made me reflect much more deeply on the culture of organisations, and critically what was my role as a leader and member of a Board, in shaping the culture of those organisations.

Another thing I gained from the Mid Staffordshire inquiry was a deeper understanding of the importance of learning from when things go wrong and using that learning to drive improvement. Things will go wrong even in the best organisations. The issue is not whether they will go wrong — they will! But when they do, how do you learn from incidents and then translate that learning into improvement?

The Toyota inspired ‘lean theory’ is an example of an approach to quality improvement which has informed many improvement techniques in healthcare. Patient deaths in US hospital groups were used as a springboard to drive improvements in quality and safety where learning from incidents was key to improvement.

When things go wrong, how doyou learn from incidents and then translate that learning into improvement?

The concept of a ‘just culture’ has also been influential in my own thinking.

A just culture is one that recognises that people make mistakes and does not seek to blame people because they make an error. Indeed, it recognises that learning from mistakes is an important part of organisational learning and improvement.

This approach requires trust and organisational maturity. It is not a ‘no blame’ culture, as it does recognise culpability for negligence or recklessness and treats those behaviours accordingly. In a just culture, people are encouraged, and indeed rewarded, for providing essential safety related information — in effect for doing the right thing in a transparent way. The evidence is that where this model exists then the organisation and staff benefit.

In a just culture, there is clarity about where the line is drawn between acceptable and unacceptable behaviour. There is literature on this which explores the concept as it applies to medicine, industry and other sectors. But it encouraged me to think about its application to the work we do in CQC.

The model describes that where human error occurs through a slip, a lapse, a mistake or just bad luck then the response should be to console. Where there is behaviour which is described as risky because people make a choice where a risk is either not recognised or people mistakenly believe is justified then the response should be to coach. Where there is a conscious disregard of unreasonable risk or reckless behaviour then the response should be to take remedial or disciplinary action. On the other hand we should celebrate difficult decisions which turn out to be good or great ones.

In my view, the journey to becoming an open and transparent organisation requires the development of a just culture.

A just culture recognises that learning from mistakes is an important part of organisational learning and improvement

There is a paradox here that brings us back to VUCA. As deference and trust has been eroded in public life over the past few decades, the discussion when things go wrong can focus on ‘who is to blame? Who will be held accountable?’ This was evident in child protection where the conclusion of inquiry reports in the 70s and 80s was that “the system failed baby/child X”, to the 90s and 00s where the Laming Inquiry into the death of Victoria Climbié identified responsible individuals. In Baby P’s case, the Director of Children’s Services at Haringey Council, Sharon Shoesmith was dismissed from her role.

Some do not seek to blame. They seek to understand, to be told the truth so they can come to terms with what has happened.

I know in my current role when I have accepted we got things wrong there were calls for someone to blame, rather than focusing on how we learn and improve. In many respects the creation of a safe space so that learning can take place alongside a clear system of accountability is what we require for the future. The escalation of that learning into improvement and a standardised approach to quality and continuous improvement is critical for future success. One of the great challenges of leadership in the public sector is being transparent and open, admitting mistakes in a culture of blame and accountability.

It takes brave, credible and confident leaders to accept mistakes, but in my view it is essential to the creation of a truly learning organisation.

Collaboration

The policy ambition of integration has manifested itself throughout my 40 years. If I was to compare how leaders became successful in the 70s, 80s and 90’s it was through being very good at running their organisation or service. However, in the coming decades, success will be determined by how effectively leaders and organisations collaborate as well as run their organisation.

When health and care services are supporting people of all ages with complex, co-morbid conditions there will be a necessity to use different professional skills from across different organisations and professions.

Success will be defined by how organisations, professionals and services work with others. Collaboration is about behaviour, but it is also about trust, and it is certainly about much more than governance. The challenge is not whether we collaborate but how we collaborate. My personal view is that the national accountability system (including CQC) is still designed around organisational success, not system or network success. It is individual organisational behaviour that is rewarded rather than collaborative behaviour. National systems need to be further developed so that collaborative behaviour is incentivised at organisation system, organisation and individual leadership level. This is one of the reasons I would encourage the Department of Health and Social Care to change the legal framework to enable CQC to regulate local health and care systems as well as organisations.

In the coming decades, success will be determined by how effectively leaders and organisations collaborate as well as run their organisation

Our report, Beyond Barriers, bringing together our findings and recommendations for change from reviews of 20 local areas was recently published. It looks at how systems are working together to provide high quality, joined up care for older people within a local area. Unsurprisingly, we found that strong system leadership is crucial. System leaders at a local level having a shared purpose and endeavouring to work together in collaboration sets an expectation for staff that then translates into the right care, in the right place, at the right time for older people.

Some of the key themes that came out of the reviews include:

  • Leadership and collaboration: In systems which have a clear, agreed, shared vision and strong relationships between key partners and coordinated care, older people receive good care. However, without these ingredients, a systems’ ability to achieve positive outcomes for people who use services, their families and carers is significantly compromised.
  • Prevention: More focus is required to keep people well and support people to stay safe and well in their own homes (including care homes). Effective prevention can reduce secondary care admissions. This requires truly integrated commissioning and provision which is joined-up around the individual.
  • Incentives for collaboration: The current performance and regulatory system and funding flows focus on individual organisations and can act as a barrier to organisations working together to meet the needs of individuals. Developing the performance and regulatory system as well as financial systems so they incentivise health and care partners to work together is key for the future improvement of care for older people.

The integration of health and care services has been a policy objective for the past 44 years. Beyond Barriers explores why, after so long, there is so little trust joint care. Our conclusion is that a significant reason is that organisations and professions do not collaborate more is because national and local systems do not incentivise collaboration.

Those points are mostly about collaboration, both with the wider system and with the CQC. The other important points are reiterating what I have already said about clarity on role, purpose and powers.

Things I wish I had known

So there you have it: things I wish I had known in the 80s, 90s and 00s that may have helped me then, and which I offer as a way of meeting the challenges in the future. They have helped me today. On a good day I hope I practice what I preach, on a bad day (we all have them!), I struggle to practice them.

  • Purpose
  • Values and behaviour
  • Staff engagement
  • A culture of learning, openness and transparency; and
  • Collaboration

So no matter your position, and no matter how great the challenges may seem, never fall into the trap of believing you are powerless, voiceless or choiceless. You are not!

You can read more from Sir David in the Guardian, and catch up with his interview with BBC Radio 4’s World at One