Theme 1: Leadership

Direction of travel

There is positive progression with the development of effective and coherent system leadership. There are capable leaders, early evidence of a shared vision, and a focus on inclusion, sustainability and improvement. However, there are risks caused by fragmented governance and limited engagement with the system by some partners.

Summary of strengths

  • The integrated care board (ICB) has a stable and capable leadership team and the integrated care partnership (ICP) has representation from across health and social care. Relevant leaders are involved in decision making, including those from the voluntary sector and emergency services.
  • Local leaders have a clear vision and plan to develop the Dorset system, underpinned by a constructive and inclusive culture.
  • The vision and strategy for Dorset ICS were co-produced with extensive engagement and consultation across Dorset populations. System partners are committed to this vision and there is a clear ‘road map’ for the system.
  • There is focus on addressing local workforce challenges, for example workforce education development programmes and recruitment initiatives. This approach is jointly owned by organisations across the system in Dorset.
  • There is high potential for technology and data tools, such as The Dorset Intelligence & Insight Service, to support effective commissioning and allocation of resources.

Areas for development

  • There are opportunities to progress strategies and plans into clear deliverables to enable them to have an impact, and ensure all activity is scalable and aligned with system objectives.
  • There is a need to balance the focus on both immediate operational challenges and longer-term resilience measures for population health and the system.
  • There is scope to improve how to use data to identify system priorities for high impact interventions.

Summary findings for quality statements under the Leadership theme

This theme includes these quality statements:

Quality statement: Shared direction and culture

Key messages

Partners in the ICS share a clear vision and there is early evidence of a developing shared direction and culture, but this is not yet consistently put into practice. There were many examples of ICB and ICP initiatives to engage organisations, the workforce and residents in the development of a common vision and purpose.

Using an evidence based, population-wide strategy

The ICS has an ambitious 5-year joint strategic plan to improve the health and wellbeing of people living in Dorset. There was broad engagement to develop the plan including '100 Conversations' with people across Dorset to agree priorities and 5 core objectives for the system to reduce health inequalities. The NHS Dorset Joint Forward Plan (JFP) 2023-2028 was informed by staff from health and care organisations across Dorset.

The Dorset Integrated Care Partnership Strategy 2022/23 is focused on prevention and place-level activity with a shared vision and commitment for the system to work together across 3 key priorities: prevention and early help, thriving communities and working better together. The Joint Strategic Needs Assessments for Dorset Council and Bournemouth, Christchurch and Poole Council were developed in consultation with people working in frontline health and care, patient and representative groups for people using services and residents.

System leaders articulated a long-term vision and strategic direction and recognised the value of working as an ICS. There was good buy-in to the strategy and vision among most stakeholders, staff and providers we spoke with. They described a clear ICB and ICP ethos of building connections and removing barriers to joint working. Partner organisations within the ICS were starting to align their organisational priorities to the 5-year forward plan.

However, there was a perceived gap between the development of strategies and implementation, and there were some frustrations with a perceived disconnect between strategic aims to improve population health and a focus on immediate operational priorities.

The place-based partnerships have a locally agreed shared vision

There was strong connection and shared priorities among voluntary community and social enterprise sector (VCSE) organisations. VCSE representatives reflected intent and desire to play an integral role at system level, but felt the commissioning model could be a barrier to joined-up working.

There were some positive initiatives to improve collaboration and shared priorities. However, some provider groups, such as those representing homecare (domiciliary) services and care homes, expressed concerns about fragmented funding and limited involvement in developing a shared direction.

The system architecture and information to support delivery and bring places together is in early stages. There is a gradual move to integrate health and social care for more equitable voice in decision making and a shared ambition for place-led design of solutions. System leaders acknowledged the need for clinical expertise and leadership within the system and the GP Alliance represented local GPs in decision making.

There were some good connections and shared aims at executive, manager and operational level across organisations, and some alignment between places. The ICS leaders articulated aspirations for a Pan-Dorset culture and shared ways of working. However, the strong sense of place in Dorset and in Bournemouth, Christchurch and Poole meant each place identified as a singular, defined area and the two places were not working in partnership as equals. In certain areas, places were developing at a different pace, which hindered collaboration and joint commissioning.

Both councils are represented at ICB, ICP and other system level meetings. There is a shared Director of Public Health and joint public health board and opportunities for councillor interaction across both places. However, we were told there is limited exchange of ideas because of different population needs in each area. Furthermore, the two councils are at different points in the electoral cycle, so Bournemouth, Christchurch and Poole Council has a new administration and new relationships were forming.

Quality statement: Capable, compassionate and inclusive leaders

Key messages

Dorset ICS has effective and inclusive leaders that understand the context and challenges of the Dorset health and social care economy. System leaders were engaged, suitably experienced and capable, and had a clear vision and direction for Dorset services. Despite challenges integrating all place partners, there was a sense of hope and energy for positive change in the system.

Collaborative and inclusive system leadership

We saw collaborative and inclusive system leadership, including involvement of clinical and professional leaders. ICB leaders have been effective at convening voices and engaging partners across sectors and there are routine opportunities for chief executives, chairs and non-executive directors from the system to meet in their peer groups to discuss issues and collaborate. The ICP Chair is also chair of the Local Enterprise Partnership, supporting local development of wider determinants of health.

Frontline and operational staff across services described leaders as being open to feedback from different voices and bringing cultural change in the system towards greater openness and transparency, that is receptive to learning and continuous improvement.

As part of the ICS establishment in 2022, the system produced a clinical and care professional leadership framework with clinical leaders. There is recognition of succession planning needs, and cross-sector leadership development opportunities that include VCSE leaders.

The ICB follows established processes to check the background and suitability of its senior leaders. ICB board development sessions are regularly completed to support senior leaders and there is a scheduled board development plan. Board members undertake ‘Fresh Eyes’ reviews as a group, to consider the impact of the NHS Dorset board as part of NHS Dorset’s performance.

Some well-established relationships exist across the system, which support challenging conversations and movement towards a shared direction. However, there continue to be changes in leadership at provider level, which has an impact on continuity in system development.

ICB and ICP leaders recognise the importance of GP engagement and leadership in the system and have GP representation on their boards. NHS hospital trusts in Dorset have also appointed GPs to their executive teams. However, some GPs reported feeling less supported and connected to the ICB and identified limitations to their involvement in decision making and a shift towards an advisory function.

Quality statement: Governance, management and sustainability

Key messages

Dorset ICS has the necessary and expected governance and accountability systems in place, including statutory committees and routes for escalation. However, these systems are in early stage and there are challenges to ensuring they work effectively and consistently. Stakeholders reported fragmented governance structures, with challenges to integrating different services and aligning decision-making processes, particularly between ICB and place-level. Despite these challenges, there is a focus on developing robust governance structures. The ICB and system partners are actively working on strategies and structures and involving various stakeholders to improve governance at system and local level.

Governance systems

There are processes for system-level quality and safety oversight, with accountability structures such as the System Quality Group where safety and performance information are reported. Committee minutes showed some early sharing of quality issues and mutual support among partners. There are agreed system-wide quality themes for 2023/24 and a 'Shared Learning panel'.

Leaders understand the main risks, concerns and challenges within the system and clinical professionals are involved in governance structures. Clinical risks were appropriately escalated and recorded on the ICB risk register. There was less focus on longer-term system-level risks and senior leaders acknowledged there was not equal weighting to urgent and longer-term risks.

There are 2 health and wellbeing boards, each aligned to the 2 places. They have different priorities and reflect local needs, but they share a Vice-Chair. Along with the Joint Director of Public Health for both Dorset and Bournemouth, Christchurch and Poole councils, this provides consistent joint leadership. Work is ongoing to improve the influence of these boards.

Places in Dorset are in the early stages of being established, with plans to build on ongoing work to develop Neighbourhoods and system-level structures. Place-based governance is in development and delegation to place-level is limited.

There is a shared understanding and cross-executive accountability of the Pan-Dorset financial position. Financial directors across the system are closely connected and there is a System Recovery Group for executive support and ownership of system resource allocation. However, non-executive directors and councillors reported challenges in embedding wider determinants of health in financial decision making, and focus on process metrics rather than prevention and outcome metrics. They felt they did not always have necessary information to measure the impact of spending decisions.

There is a push to collect and use data effectively and efforts to systemise how data are used to inform decision making. However, despite having access to a wide range of data, collection of data by the ICS was variable and quality data were not consistently used to inform decisions, for example to inform the impact and effectiveness of initiatives on prevention, community health and wellbeing over time.

Quality statement: Partnerships and communities

Key messages

Leaders in the ICS demonstrated understanding of who they needed to collaborate and work in partnership with and acknowledged that more engagement with some partners, communities and residents was needed. Overall, we found a collaborative and community-centred approach in the ICS. There were early-stage initiatives to focus on outcomes, digital integration and a genuine effort to engage with diverse communities.

System-wide process objectives and processes

The ICB and ICP have involved residents from different communities in making decisions, including people who are in more vulnerable situations, using initiatives such as surveys and outreach programmes. Initiatives such as ‘100 conversations’ and engagement with the voluntary and community sector (VCSE) demonstrated a commitment to understanding community needs and embedding their views in Pan-Dorset strategies and plans.

The ICB is moving towards outcomes-based commissioning and devolving commissioning decisions to place level, to enable more holistic and targeted interventions for meaningful, measurable improvements in community wellbeing. ICB leaders articulated their role in proactively bringing the system together to facilitate local transformation and delegate decision-making.

The ICB has a dedicated health inequality lead, system-wide health inequalities programme and steering group to bring together different sectors to identify and address root causes of health inequalities. New ICS structures have facilitated a more strategic interface between public health and housing teams. However, housing associations do not have a formal voice within the ICS.

Senior leaders within the ICB and ICP acknowledged insufficient engagement with schools and colleges and a need to improve outreach efforts to enhance health education among young people. We also received feedback of limited engagement with certain groups such as people in rural communities, indicating gaps reaching some populations.

How the ICS works collaboratively to address the needs of its population

Well-established networks of relationships between different sectors facilitate information sharing and collaborative working. The ICB has started to build strong partner relationships to develop its understanding of community needs and resources. However, there was inconsistent engagement and partnership working between some community organisations. Some providers described some persistent "protectionist and tribalistic" thinking hindering progress towards integration.

There are 7,700 voluntary and community sector (VCS) organisations in Dorset, employing 15% of the local workforce, with 58% focused on health and wellbeing and 15% involved in social care. The Dorset VCS Assembly was created in 2022 as a forum for VCSEs to share ideas and issues and support connections with public sector partners. The VCS Assembly has two representatives on the ICB Board, with 2 further places allocated for attendance on specific agenda items.

The ICB is tentatively investing in community-based projects as the building blocks for neighborhood teams. Various volunteer initiatives, driven by community needs, showed local communities working collectively as models for neighborhood development. VCSE leaders told us ICB engagement felt like a partnership, but the ICB does not engage all VCSE organisations equally and non-recurrent funding is a problem for some organisations to maintain their engagement and sustainability.

Quality statement: Freedom to speak up

Key messages

The ICS is starting to develop a system-level approach to freedom to speak up (FTSU). The system is early in this work and has not yet developed written or structured plans to bring together speaking up processes across the system.

How freedom to speak up roles and processes are embedded within the organisations and the system

Freedom to speak up and whistleblowing leads from organisations across the system had a clear and shared understanding of speaking up. Health and social care staff could describe what speaking up was and how to do so in their own organisations. Leaders showed commitment to raising the profile of speaking up at system level and are holding wellbeing and speaking up engagement events. Staff could articulate examples of speaking up with system support with appropriate investigation and resolution.

The ICB’s freedom to speak up policy published in December 2022 was in line with national policy. Staff and leaders had plans to develop a co-ordinated system response to speaking up and were on track to deliver this in the next 12 months. There were priorities to implement routes for speaking up, embed a freedom to speak up guardian and speaking up mechanisms for staff working in the ICB and using the improvement tool to map their plan over the next 3 years (in line with national requirements from January 2024).

Training, support and flexibility for Freedom to Speak Up Guardians

The ICB has 2 Freedom to Speak Up Guardians and an executive and non-executive director lead for speaking up. They are trained in receiving concerns, supporting and signposting staff. Staff with speaking up roles reported sufficient time and support to discharge their responsibilities. They described strong speaking up mechanisms in their host organisations, and networks were in place to share information and good practice.

Quality statement: Learning, improvement and innovation

Key messages

We found early indications of a system-wide learning culture and shared efforts to innovate and improve services. Dorset ICS has access to powerful data tools and strong connections to collate information from different parts of the system. There is a clear focus on using feedback to improve services. However, it was too early to see how data would be used to monitor progress and measure the impact of learning and improvement initiatives. Learning is not consistently shared between places or from national level, which risked mistakes being repeated across providers and sectors.

Local partners enabled by a system-wide learning culture

The ICB used system architecture to collate and analyse risk information relating to specific services and sectors. For example, using patient satisfaction survey results, Quality and Outcomes Framework results and a self-reported GP alert system as control measures to target support to GP practices. ICB support had resulted in reduced elective surgery waiting lists and system improvements to urgent and emergency care pathways. However, learning from high performing organisations could be better shared and implemented across the system to improve equity and recovery of services.

Tangible and measurable improvements in quality, performance and outcomes

The ICS has invested in digital solutions such as Dorset Intelligence and Insight Service (DiiS) to use data for targeted interventions. The DiiS tool is at the forefront of Dorset’s analytical response, linking data from primary care, acute and community providers on a near real-time basis. DiiS contained massive data sets, which will help clinicians and commissioners to understand local pressure points, specific areas of concern and to interrogate a bigger picture of health needs across Dorset.

Staff across the system recognised the importance of a learning culture and there were examples of good system-wide learning, for instance in pan-Dorset safeguarding structures. Staff describe making sure solutions are right for staff and the population using them.

Some VCSE leaders felt there was a gap in engagement and planning strategies for people who were digitally deprived and there were concerns some residents were not able to participate because of the move to digital engagement. VCSE leaders acknowledged digital champions were in place but thought now was the time to ensure that as services have a bigger focus on digital solutions, less digitally active residents of Dorset are not left behind.

Innovation initiatives are evidence based and evaluated on an ongoing basis

There was some evidence of innovation and early shared learning approaches across the system. These were mostly provider-led initiatives rather than enabled or facilitated by the system.

Local higher education institutions had established a Dorset alliance to work together on research and development across disciplines. The ICB DiiS team and primary care networks designed a tool to identify patients who were not on a palliative care pathway when they should be, and to help them to find the right support. It was anticipated this would improve people's experience of end-of-life care and reduce inappropriate admissions to hospital.

Quality statement: Environmental sustainability

Key messages

Dorset ICS leaders and staff understood the negative impact of health and social care activities on the environment. There are some early outputs to reduce this impact, including a green plan to embed and progress the sustainability agenda.

The NHS Dorset Joint Forward Plan 2023-2028 sets out ICS sustainability in terms of finance, social impact and the environment. The NHS Dorset Consolidated Green Plan 2022 captures all work being undertaken by Dorset NHS partners, with a shared mission to offer excellent health care in a way that respects the needs of this and future generations. Dorset NHS organisations have committed to reduce their core carbon footprint by 80% by 2030, focused on sustainable estates, procurement and consumables.

There was some progress towards 11 system environmental priorities, including nomination of sustainability leaders and green champions, reducing paper records and encouraging active staff transport. There were good sustainability measures within pharmacy provision at University Hospitals Dorset NHS Foundation Trust as an early sustainable pharmacy champion. All medicines tenders have a sustainability check and the hospital has switched to specific medicines to reduce environmental impact. This is being expanded across Dorset and the south-west.

Governance and accountability reporting structures for sustainability include an executive lead and sustainability leads for each NHS trust. The ICB Chief Medical Officer has board level responsibility. There is no non-executive director equivalent. A monthly green plan group reports into the health inequalities group. Board and sub-committee reports and minutes did not show evidence of environmental sustainability papers submitted to the health inequalities group.

Quality statement: Workforce equality, diversity and inclusion

Key messages

Equality, diversity and inclusion (EDI) is a priority for system leaders and partners with a drive to recruit and retain a diverse workforce that reflects local populations of Dorset enshrined in the ICS People Plan. There are some mechanisms to improve recruitment and support existing staff from different backgrounds, including international recruitment initiatives and establishing staff diversity networks. Some interventions are system-wide, but most were at provider level.

The ICB used an organisational development approach to embed EDI across the ICS and create an inclusive, values-based culture. The ICB funds specific EDI training for system partners. Leaders acknowledged many EDI activities are in early stages of development with limited impact. However, although the aim was for diverse, local recruitment, health and social care staff and leadership in some organisations were not yet representative of local populations and there was limited diversity across protected equality characteristics, which executive leaders acknowledged. For example, in 2023, 3% of ICB staff bands AfC 1-9 are from an ethnic minority background, compared to 7% in the ICS overall (UK Census 2021 data)

At the time of reporting, NHS Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) data for Dorset were available up to 2022 only. Only NHS hospital and mental health and community trusts submit WRES and WDES data.

For NHS providers across Dorset, WRES data indicated slight improvements in diversity of representation as a result of international recruitment, but Dorset remained below the national average, with a likely increased disparity of lower and middle bands to senior leadership representation. There were some slight improvements with experiences of discrimination, but generally worse experiences of harassment, bullying or abuse from staff.

For staff working in NHS Dorset ICB, the experience of staff from an ethnic minority background is generally worse than the experience of staff in White ethnic groups, but better than the national average. While 12% of these staff and experienced harassment, bullying or abuse from patients, relatives or the public in the last 12 months, only 5% of staff in White ethnic groups did. These experiences are better than the national average (28% and 23% respectively). The proportion of NHS Dorset staff experiencing discrimination at work from a manager, team leader or colleagues in 2023 is higher for staff in ethnic minority groups at 6% than for staff in White groups at 4%, which is better than the 2022 national average (17% and 7%respectively).

For NHS providers, WDES data indicated a mixed experience. It indicated improvement in disabled staff experiencing harassment, bullying or abuse versus non-disabled staff from other managers at 6%, and at 2% from other colleagues. Both indicators are better than the national average. Disabled staff felt less valued than non-disabled staff, a difference of 7.6%, and staff feeling that adequate adjustments have been made to enable them to carry out their work has declined from 95% to 90%.

There is good provision of staff equality and inclusion networks at the ICB. Some staff told us fewer people engage with people in ethnic minority groups because of perceived mistrust and hesitancy due to historically differential treatment. Each network is represented in the ICB EDI steering group, which looks at equality impact assessments, leadership and accountability, pay gaps and workforce wellbeing and culture. This feeds into ICB governance structures for escalation and accountability.