The document provides an evaluation report on leadership and strategy for the Leeds Institute for Quality Health Care (LIQH) from January 2015. Some key findings include: 1. LIQH has embraced quality improvement and systemic change as a core strategy, bringing about system-wide changes focused on quality, though this presents challenges. 2. Leadership activities at LIQH demonstrate common goals and alignment of activities across organizations, reflecting the importance of consistent leadership. 3. LIQH is developing clinical leadership and supporting it with professional management, with emerging professional leadership seen across Leeds. 4. There is evidence of LIQH building long-term relationships, consciousness of constraints, and wider leadership beyond its programs. Overall the report finds

1. EVALUATION REPORT
LEADERSHIP & STRATEGY
JANUARY 2015

2. STRATEGY 2014-2020
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ACKNOWLEDGMENTS
With thanks to Dr Kieran Mervyn and Dr Nii Amoo from AM2 Partners Ltd for the data
analysis and report which forms the basis of this report.

3. STRATEGY 2014-2020
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CONTENTS
EXECUTIVE SUMMARY P3
INTRODUCTION P6
OVERVIEW OF EVALUATION MODEL P7
METHODOLOGY P8
QUALITY AND SYSTEMATIC IMPROVEMENT AS CORE STRATEGY P11
LEADERSHIP ACTIVITIES EMBRACE COMMON GOALS AND
ALIGN ACTIVITIES THROUGHOUT THE SYSTEM/ NETWORK OF CARE P19
CLINICAL LEADERSHIP IS SUPPORTED BY PROFESSIONAL
MANAGEMENT P23
SHARED DECISION-MAKING WITH PATIENTS AND FAMILIES P27
EVIDENCE OF WIDER IMPACT P31
THE IMPACT OF LIQH AS A TECHNOLOGY1 TO GENERATE
IMPROVEMENT IN HEALTH CARE IN LEEDS, IN THIS CONTEXT P34
OTHER EMERGENT ISSUES FROM THE INTERVIEWS P40
ADDITIONAL LESSONS P44
CONCLUSIONS P46
CHALLENGES P50
REFERENCES P55
APPENDIX 1: SUMMARY FROM THE BASELINE INTERVIEWS
MAY 2014 P56
APPENDIX 2: YEAR ONE IMPACT REPORTED IN ANNUAL
REPORT JAN 2015 P58
1
The collection of techniques, methods and processes used within LIQH

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EXECUTIVE SUMMARY
“I HAVE BEEN ON OTHER EDUCATIONAL VISITS, MAYBE NOT ABROAD BUT
WHERE EVERYBODY COMES BACK, EVERYBODY THINKS IT WOULD BE
USEFUL TO DO SOMETHING LIKE WE’VE SEEN, BACK AT THE RANCH, BUT
NOTHING HAPPENS. SO, I THINK THE FACT THAT IT’S HAPPENED, THAT
EVERYBODY’S SIGNED UP TO IT, THAT THERE ARE PEOPLE FROM ALL THE
ORGANISATIONS WORKING TOGETHER, IS ABSOLUTELY MASSIVE” .
This report was commissioned by The Leeds Institute for Quality Health Care (LIQH) to
understand and evaluate the role LIQH is playing in the development of Leeds as a high-
performing healthcare system particularly in relation to systems leadership, and to unearth
the challenges and opportunities to its development.
This study builds upon a scoping pilot study in May 2014, and intensive literature review
undertaken for LIQH2
July 2014, by reporting further on the activity and deeper impact of
the LIQH as a technology. This evaluation looked at LIQH’s progress to date in the context
of Dennis & Bakers (2011) grid3
on high performing health care systems and hypotheses
generated from LIQHs scoping review by critically evaluating the influence and
effectiveness of the LIQH model.
KEY FINDINGS
Leadership for quality
 LIQH has clearly embraced quality and systemic improvement as a core strategy, and
various examples illustrate how LIQH are managing to bring about system wide
changes focusing on quality; however this is not without its challenges.
 Signs of consistent leadership that embraces common goals and which aligns
activities throughout the organisation were reported and reflects the LIQH’s scoping
review on collaboratives which highlighted the importance of an equal and enabling
atmosphere within large-scaled collaboratives underpinned by consistent leadership
that motivates and encourages all members to work as a functioning unit.
 The relationships generated between the voluntary and community sector and the
public sector through LIQH has lead to new opportunities for the third sector and new
possibilities for the future.
Supported Clinical Leadership
 The report illustrated how professional management is supporting clinical leadership
and how LIQH facilitates this, and it was notable how lucid and more authoritative
professional leadership is emerging across Leeds. LIQH is clearly developing Leeds
as a culture of learning in Health Care Systems.
 There was wide reporting of the effect of LIQH on individuals and the people they
work with, creating the conditions for a dispersed model of leadership to work, and
enabling teams to do really good work together across the system
2
Mervyn K, Amoo N. 2014 Brief Literature Review on Improvement at Systems Level. The Leeds Institute
for Quality Healthcare
3
Baker R and Denis JL .2011. A Comparative Study of Three Transformative Healthcare Systems: Lessons
for Canada. Canadian Foundation for Healthcare Improvement. Canada

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Professional culture of teamwork, accountability and improvement
 There is growing evidence of LIQH programme participants building long-term
relationships, being conscious of each other’s organisational practices, governance
and financial constraints, and engaging in problem solving, change initiatives and
wider leadership beyond the confines of the programmes.
 LIQH is creating the conditions to ensure that effective change management and
health care improvement are focused on the whole of patients’ experience.
 Effective learning strategies and methods to test improvements and scale-up were
reported, and the importance of a common language (involving the tools, frameworks
and measurement methods) used for clinical improvements was highlighted.
 LIQH have embedded systems leadership with learning and provides learning
experiences across the whole patient experience.
Shared decision-making with patients
 The coproduction work is clearly inspiring and there is a real appetite for coproduction
approaches, with a view that LIQH can really help the city achieve such a big ticket
issue. However this one of the bigger challenges in the LIQH work, as its so different
from the status quo; and will take time to do well.
Impact
 Whilst the Leadership activities of the LIQH are clearly enabling applied development
activities, this is quite slow and incremental and therefore in line with experts such as
Baker & Dennis (2011) who encourage such an approach for sustainability and
accountability purposes.
 There is compelling evidence of incremental progress; improved shared decision
making; changing behaviour at system level; spread of impact outside the direct work
of LIQH; service level changes.
 LIQH has contributed in respondents views to:
 Getting 7 day working going in Leeds
 The relative ease of managing winter capacity this year
 Funding for grants allocated to Leeds Community Foundation for health and
social care sector development
LIQH’s as a technology
 It was found that LIQH is clearly different from other places through its strategic
objectives, form and function. Its emphasis on a whole place-based approach is at
odds with other organisations, networks and forums that tend to adopt an issue based
approach to scaled improvement.
 A range of interesting opportunities that LIQH enables so as to address challenge in
Leeds Health Care System were reported, and the differences and uniqueness of
LIQH were inextricably highlighted and shown to differ to other forums of
organisational forms that currently operate in the Leeds area for healthcare
improvement.
 It was illustrated how the university and Health connection is offering a much needed
and intellectual and pragmatic link between academia and practice, and also enabling
the development of enabling shared spaces.

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 Many positive inferences were made about the relationship between the
Transformational Board and LIQH activities, and it was reported that LIQH can directly
assist the transformation board in various ways, but should remain at arm’s length and
not come under its control.
 Underpinning any high performing system, is the role of the strategic leader, and the
need to promote professional cultures that support teamwork, continuous
improvement and patient engagement was noted. This was widely acknowledged and
evident from the majority of respondents who seen real value in the CIHM Directors
role in steering the Institute in conjunction with others.
LIQH’s Future
 LIQH came into being at the right time during the reorganisation of the NHS and age
of austerity, and it was widely acknowledged that LIQH should be supported by Leeds
healthcare leaders and should continue to exist in the medium to long-term as a fluid
blend of a dynamic platform, network and forum.
Ongoing Development
 Issues arose such as the need for more strategic buy-ins, and also, interestingly,
wider grassroots buy-in (besides GPs and Consultants) was needed in the LIQH
programmes.
 Mixed views emerged about the process of developing a shared narrative, and a
range of challenges facing LIQH were reported.
 We show how LIQH is addressing change and project management, and also
undertaking shared decision-making with patients and families and Co-Production.
 Overall, there is a real sense of anticipation and expectation about the possibilities for
scaling up to address larger and more vital priorities such as urgent care, however
the current and incremental development seen in year one illustrates the potential for
LIQH and hence the approach adopted was seen as innovative, impactful and well
received.

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INTRODUCTION
LIQH takes the lessons on improvement collaboratives and coproduction, networks and
systems leadership to establish itself as a Collaborative Improvement Network.
It’s focus on system governance (process, structures, values, leadership) to enable
clinical innovation and learning makes it different from previous collaboratives.
The evaluation of LIQH addresses three levels
1. The impact of LIQH as a technology4
to generate improvement in health care in
Leeds, in this context
2. The impact of the clinical priorities – the improvement and change teams work
3. The impact of the systems leadership interventions to create the conditions for
improvement across the whole of Leeds
This report is part of a series of evaluation reports.
To date these have been:
1. The systems leadership interviews – baseline May 2014 (providing baseline data on
systems leadership in Leeds in relation to high performing health systems)
2. The Annual Report year one – December 2014 (which covered the impact of LIQH
including the impact of the specific separate interventions to date). Summary
provided at Appendix 1
This report focuses primarily on evaluation level 3: Systems Leadership; but because of
the interrelation of the interventions in the technology as a whole the report also provides
some data on Levels 1 and 2 (LIQH as a whole and the clinical priorities)
This report will be followed in the Summer of 2015 with a report specifically on the
Clinical Priorities.
4
The collection of techniques, methods and processes used within LIQH

8. STRATEGY 2014-2020
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OVERVIEW OF EVALUATION MODEL
The evaluation models for Leeds institute for Quality Healthcare is informed by a literature
review5
of improvement at systems level; and the international research undertaken by our
partner Prof Jean Louis Denis into High Performing Health Systems6
.
HIGH-PERFORMING HEALTH SYSTEMS
Table 1: Critical Themes in High Performing Systems Adapted from Baker & Denis
2011
Leadership &
Strategy
Organising Design Improvement
Capabilities
Quality and systemic
improvement as a core
strategy
Robust primary care
teams at the centre of
the delivery system
Proactive approach to
building skills for quality
improvement across the
system
Leadership activities
embrace common goals
and align activities
throughout the system /
network of care
More effective integration
of care that promotes
seamless transitions
Information as a platform
for guiding improvement
Clinical leadership is
supported by
professional
management
Promoting professional
cultures that support
teamwork, continuous
improvement and patient
engagement
Effective learning
strategies and methods
to test and scale up
across the system
Shared decision-making
with patients and families
Providing an enabling
environment buffering
short-term factors that
undermine success
Engaging patients in the
their care, and in the
design of care
It is the first column that is attended to in this evaluation report.
5
Mervyn K, Amoo N. 2014 Brief Literature Review on Improvement at Systems Level. The Leeds Institute
for Quality Healthcare.
6
Baker R and Denis JL 2011. A Comparative Study of Three Transformative Healthcare Systems: Lessons
for Canada. Canadian Foundation for Healthcare Improvement. Canada

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EVALUATION HYPOTHESIS
Based on our literature review, quality improvement across a health system requires :
 A change in the governance of the system as a whole which requires system leaders
to relinquish territory in service to a wider shared and visible common purpose
 A professional culture of teamwork, accountability, and improvement
 Shared decisions with patients and carers
 Evidence of impact
The combination of the hypothesis generated from the literature and the specific
characteristics of leadership and strategy in high performing health systems as identified
by Baker and Denis (2013), forms the framework for this evaluation.
This report addresses the following dynamics of Systems Leadership as a result of LIQH
interventions:
 Quality and systemic improvement as a core strategy
 Leadership activities embrace common goals and align activities throughout the
system/ network of care
o A change in the governance of the system as a whole which requires system
leaders to relinquish territory in service to a wider shared and visible common
purpose
 Clinical leadership is supported by professional management
o A professional culture of teamwork, accountability, and improvement
 Shared decision-making with patients and families
Along with an ongoing summary of
 The evidence of impact
And a summary of view of
 The impact of LIQH as a technology

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METHODOLOGY
A longitudinal study was undertaken at different stages during 2014.
STAGE 1: BASELINE DATA
The primary technique for collecting the first set of qualitative data was a self-developed
questionnaire which underpinned: ‘A qualitative exploration into systems leadership
practices and experiences of senior health leaders and clinicians in Leeds’. The
researcher conducted 12 semi-structured interviews during May 2014 with senior health
and social care leaders in Leeds. The purposeful sample was intentionally selected to
learn and understand the central phenomenon (McMillan & Schumacher, 1994: Miles &
Huberman, 1994). Participants were invited to join the study who would best answer the
research questions and who were “information rich” (Patton, 1990) and to “produce an
understanding of the problem based on multiple contextual factors” (Miller, 2000). The
questionnaire consisted of nineteen questions, which were organised into four sections
containing open ended questions to establish a “complex, holistic picture, analyses the
words, reports detailed views of informants, and conducts the study in a natural setting”
(Cresswell, 1998).
 The first section of the questions related to personal thoughts on performance and
practices in health systems leadership across Leeds.
 The second section was to assess motivators and barriers to working collaboratively
and provide additional data about the impact of the Leeds Institute for Quality
Healthcare.
 The third section asks for a self-evaluation of opinions of own leadership style and
effectiveness.
 The fourth section was focused on how the Institute could improve its contribution
and develop more effective relationships.
Lastly, looking at Critical themes of systems leadership in high performing systems
(adapted from Baker & Denis 2011) and using a scale 1 to 10, interviewees were asked
to score current performance against the four Leadership & Strategy sub sections. The
research was aimed to establish initial baseline findings for the Institute as an inquiry
process. The interviews were transcribed and analysed by thematic identification by two
readers of the text. The themes were compared and aggregated across all the interviews.
The summary of the baseline study is provided at Appendix 1.
OVERALL WHILST THERE WAS GOOD INTENT ACROSS THE LEADERS TO WORK TOGETHER
THERE WAS DISPARITY IN VIEWS ABOUT BOTH WHAT (IN TERMS OF PRIORITIES) AND HOW
(WAYS OF ACHIEVING CHANGE), AND NO SHARED NARRATIVE.

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STAGE 2: 6 MONTHS INTERVIEWS
A follow-up study of senior interviewees was undertaken for this present study in
November 2014 using the same selection criteria but therefore not necessarily
interviewing the same sample. NVIVO was used to store and manage the 21 transcripts
and undertake coding of the responses. After an initial round of transcript reading, each
of the interviewee transcripts were then rigorously re-reviewed, by creating free nodes
(see below) which were the less organised ideas and segments emanating from the text.
Table 2: Initial Free Nodes
 Alternative Forums to LIQH.  LIQH Challenges
 Attendance at LIQH events  LIQH is the correct forum
 Balancing Day Job v LIQH  LIQH's Strategic Aims & Objectives
 Buy-In Dilemma & Relinquishing
Territory
 Memberships
 Coproduction  Need for LIQH
 Coming into contact with LIQH  NHS Professional + University
Leader Relationships
 Compare LIQH events with similar
events
 Perceptions of LIQH's Leadership
Programmes
 Doing Differently Now v Before  QI + VFM + cost effectiveness
 Evidence of Impact  Senate Medical and Nursing
 Inter-professional Collab Working
Attitudes and Approach
 Shared Narrative Thinking and
Appreciation
 Leadership Programmes & Systemic
Change
 Take-aways from LIQH events
Free nodes then helped the researchers to identify higher level themes which were
linked to the questions around high performing health care systems (Baker & Dennis,
2011). All interviews were transcribed verbatim. Free nodes were regularly reviewed as
new transcripts were coded to identify whether themes pertaining to the research
questions had continued through following interviews. An element of more focused
coding was undertaken which emphasised some of the more emergent themes. The
literature was also subsequently explored in order to underpin, refute or support the
evaluation findings.

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QUALITY AND SYSTEMATIC IMPROVEMENT AS CORE STRATEGY
“THE INSTITUTE IS TRYING TO BRING TOGETHER CONDITIONS IN A WAY TO DRIVE FORWARD
SYSTEM LEADERSHIP. ALSO FULLY BOUGHT INTO THE IDEA OF CLINICIANS ACROSS THE
SYSTEM TAKING A LEADERSHIP ROLE, AND ALSO LOOKING AT THE QUALITY DIRECTLY AS A
WAY OF IMPROVING THE QUALITY OF CARE, BUT DOING IT ON A SYSTEM BASIS AS OPPOSED
TO A SINGLE ORGANISATION.”
The core strategy and objectives for LIQH are to improve quality of care and at the same
time secure best value; develop a culture of professional learning, innovation and shared
decision-making with patients; and apply a robust health improvement methodology in a
city-wide improvement collaborative for Leeds. This should be built on local co-existing
cultures in Leeds and utilise the intelligence from best systems internationally. Almost all
of the respondents agree to this strategy and objectives, in regards to the Institute and
what it seeks to achieve, and how.
One of the top attributes of a high performing healthcare system as illustrated in the
Baker and Dennis (2011) grid is the quality and systemic improvement as a core
strategy, and most of the respondents agreed that LIQH is meeting this attribute. For
instance, R10 strongly inferred as he noted that:
“I just think that is at the heart of what it does really, is to – the ecology is very key in
the way stuff’s been set up and the reasons for the setting it up… There’s an element
that some of it is also about cost and it has to be that that’s a sort of opportunity to look
at stuff, but yeah, no it feels like it’s very core in what’s done”. 7
7
When asked to rate it on a scale of 1-7, R10 rated as 6.
SUMMARY
Respondents
 Agree with LIQH strategy and objectives.
 Value the approach of combining local culture and ambition with international
intelligence
 Report the significant difference in LIQH from other collaboratives of the focus on
cross-system leadership and how difficult it is to do.
 Provided compelling evidence of incremental progress; improved shared decision
making; changing behaviour at system level.
 Described a culture change of shared language, confidence in working across
organisations and using new tools in their daily work, and strong team bonding in
the clinical priorities work.
 Are concerned that the understanding of how to secure quality and systematic
improvement in Leeds for who have been involved in LIQH differs from chief
executives who have been less engaged.
 Identified the need for a stronger shared narrative about system wide quality and
LIQH – that has to be both clear and emergent.
The views in this report are more uniformly held than in the baseline report

13. STRATEGY 2014-2020
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R10 views the LIQH as: “very much about bringing people together in a kind of
constellation of joined learning and joint exploration around leadership in health”. LIQHs
strategic objectives include looking at ways to work together on an economy scale, and
to make a difference that is sustainable, embedded and doable. The difference with
LIQH has been the cross-systems leadership component:
“...And that has made it unique and valuable, and I think I would really want to see it to
continue to grow and to flourish, and I would be really sad if we as a system don’t grasp
the opportunity that we now have to build on the momentum that we have created” (R16).
LIQH emerged at the correct time with the growing emphasis on quality underpinning the
bottom line rather than the financial figures determining the quality: “we’re starting to
shape up but I think the bit for me around quality is that I think it started to come to the
fore in terms of being a strategic priority in organisations” (R3).
PACE OF PROGRESS
As noted by G Ross Baker, a leading professor of health policy management and
evaluation (Baker, 2011; Baker & Dennis, 2011: p.14), ‘Few quality initiatives yield
breakthrough results in short timeframes…[and] sustained efforts to analyse and
improve care have yielded groundbreaking results in many areas’. In the present study,
there was compelling evidence from most of the respondents who recognised the small,
sustained but incremental progress that LIQH seem to be making. LIQH strategy is to
consider that the required quality improvements could be a slow but achievable objective
and small incremental changes is what is happening now (the notion of the magic bullet
is highlighted in LIQHs brief literature on large scaled collaborative for improvement8
).
Respondents referred to:
“...small pockets of evidence of impact, however there are many potentialities and a
feeling amongst network members that something powerful and exciting is being
enacted through the LIQH network” (R1).
Small incremental changes are a far better approach since that averts the risk element in
a change process. Leadership should drive this
“…but I still think there a million possibilities that we will never as a group of leaders
think of but the people in our organisations will and what we need to do are to create the
conditions for them to be able to make the changes, the small incremental changes that
are needed [i.e. 2% a 3%,a 5% improvement to be made by many people] and then
respond accordingly when those changes are being made to make sure that the
conditions then continue to adapt to allow those conditions to flourish” (R7).
“small incremental changes would be good. But also being able to demonstrate that you
are contributing to some of the big system change challenges and some of the ways that
we want to address those” (R1). Investment in QI is seen as very important because
change doesn’t happen instantly. But as R3 suggests, we shouldn’t close arms about it;
it’s positive that LIQH are doing something about it.
The need for a long term perspective requires a deliberate and sustained focus on
quality and services (Baker, 2011).
R20 believes the LIQH is “...really trying to support members of teams in the health
economy to actually learn the tools and techniques for quality improvement, and be
8
Mervyn, Kieran, and Nii Amoo. 2014 "Brief Literature Review on Improvement at
Systems Level." Leeds Institute for Quality Health Care, Leeds, England.

14. STRATEGY 2014-2020
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confident in using those tools and that philosophy and that way of working in our daily
lives really, in our working lives” (R20).
LIQH is driving the importance of quality however at a sensible and incremental level.
Respondents refer to working from an academic point of view to deliver the desired
changes in a suitable period of time and to:
“..bring people together from all walks of life in the health service economy to try and
deliver change but to simplify it as well by looking at what the academics sort of ends are
of producing change and to give those to us in a way that you can get on quiet quickly
with delivering the change but not necessarily quick in terms of overall time scales” (R2).
HOW TO BRING ABOUT SYSTEM WIDE CHANGE FOCUSING ON QUALITY IMPROVEMENT?
Several respondents inferred how system wide change could be enacted through
focusing on quality improvement. R8 stated how:
“It needs staff who are skilled in it, you need boards who understood it and who required
their staff to work in a certain way, you would need a system that paid attention to those
things that QI said are important, and you’d need that cover what I call the planning
parameters” (R8).
In order to instigate large scale change, it is vital to use a service improvement
methodology; “... it can be any type...One of the things I’ve been banging on about in the
city for ages, in Leeds, is the point that we describe some of the things we do as
systems, but –they’re not systems, they’re a collection of activities which have
developed over time, between which we try and draw connections and inferences” (R17).
Furthermore, R17 refers to urgent care being widely and incorrectly characterised as a
system rather than: “...an incremental collection of things...and if you’re using a services
improvement methodology, you actually get back to some real basic questions, and I
think we’re still not doing that”.
Systems change is already being enacted within some organisations irrespective of
LIQH’s influence, but “…what we will – what we should be doing, is actually offering
service users and carers different providers at different points of the care pathway…
which is more consistent with the broader strategic aims associated with choice in the
NHS, and so on” (R17), and further stated his view about future service developments:
“…it’s not just about where you get your hip done, what it may be is that, if you look at
that it could be about, well, you might – if you need some home support when you go
home after you’ve had your hip done, you might get that from Leeds Community Health,
but equally it might be really useful to know you can also get it from Age Concern. And
for those things we already have worked examples that are within our organisation, but I
just think we’ll do more of that in the future”.
Culture of leading together
LIQH is developing Leeds as a culture of learning in Health Care Systems by improving
Quality of Care that drives efficiency. Also, the LIQH is developing a culture of learning
because it involves building on the local knowledge and co-existing cultures in Leeds (&
within GPs) and beyond: ‘“Whether it be related to outcome or processes measures or
service utilisation or whatever. So it’s about being able to apply a robust health
improvement methodology and also to develop a culture of learning” (R1).
It was reported that strong team bonding has already occurred for participants such as
R13 as a result of PLP and journey through the pathway for Fractured Neck of Femur.
R11 sees LIQH as knitting together various previously dispersed organisations:

15. STRATEGY 2014-2020
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“[LIQH is more than just a] “....model to be used, but also …the work is very very
stimulating to think in a different way about improvement at a systems level, and I think
what’s trying to be pushed here is a different form of leadership, a collaborative
leadership through a network.
Further, it concerns “...different ways about using networks as a way of leadership
across the system, as opposed to say leadership is an organisation of which you must
have more control. LIQH is providing “...the clinical world having this space to look at
what they’re doing, improving is a necessary part of a system change”. R1 believes
collaboration and group working is a much better way to achieve results since individuals
cannot by themselves fix everything.
A CHANGE IN THE GOVERNANCE OF THE SYSTEM AS A WHOLE WHICH REQUIRES
SYSTEM LEADERS TO RELINQUISH TERRITORY IN SERVICE TO A WIDER SHARED AND
VISIBLE COMMON PURPOSE
There’s a sharp distinction between the APLP people and the chief executives right at
the top. It was reported that ALP participants tend to accept that it’s early days whilst
Chief Executive level are asking about outcomes and why outcomes haven’t been
realised. LIQH are clearly creating the conditions for collaboration with a view to gaining
better outcomes for patients across the city of Leeds. However agreements are not
easily forthcoming: “We’ve run a very fragmented system, people are rewarded and paid
for individual performance not collective performance. So to work in a collective way is
quite a test” (R14).
While LIQH is certainly not seen as a waste of time and resources, respondents such as
R2 are more interested in the day-to-day jobs in the workplace.
LIQH’s organising activities are seen as important as it had “…allowed those adult
conversations to really take place, to an extent that I don’t think they have taken place
before” (R5). LIQH has allowed a localised city-wide institute that is brought about by the
local people themselves and not a copied perfectionist or of–the-shelf model. LIQH is
also seen to be facilitating co-production and collaboration and working to “glue”
together different facets of the healthcare system together in the city of Leeds:
“We are almost like the grout between the tiles. Every other organisation are the tiles
and as primary care we have been the bit that has tried to join it all together. It’s almost
like saying, how do we get rid of those tiles so much and how do we get rid of the grout a
bit so that actually its one big tile so that everything flows through slowly”. Hence there is
a real need to try not to work in an isolated manner (R6).
LIQH has created an enabling atmosphere i.e. that facilitates shared decision making:
“...the current city wide forums that are operating where potentially you could be doing
shared decision making wasn’t happening. People were all being very defensive and
taking their position from the organisation that they sat in.” (R5).
Shared purpose and learning
Respondents see the LIQH as much more that QI training: “I have been pleased to find
that it was more than that, and the things which I have taken from it which is more than
that, is the cross-system approach and the fact that all the different organisations are all
committed to this methodology and this approach, and therefore there is much more
power behind it” (R16). However several respondents suggested that the instigation of
cultural change across the system will take patience and time.
LIQH offers vehicles for new clinicians and healthcare personnel to come into the city for
the first time to work. This helps them to get up to speed with immediate knowledge and

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understanding of the key issues within the healthcare system of Leeds. For R16, her
contact with LIQH has altered the way that she deals with leadership and decision
making in her organisation: “Yes. I think probably because I’m still relatively new in
Leeds it’s been invaluable in meeting and getting to know other people in other
organisations across Leeds, and we’re also similar level of interests, shared agendas
etcetera, so it’s [been] informal as well as formal kind of learning and sharing cultures
because we all know how things should be, you know, a huge amount of leadership is
about relationships and building networks etcetera. So, I would say, yes absolutely to
that” (R16). R16 has an externally facing role anyway, so LIQH have inextricably
supported her in system improvement by facilitating working with a range of other
organisations when she’s outside of The Institute environment:
“Oh it definitely makes it better. I’ve always worked – as a public health specialist, I’ve
always worked across the system and, you know, I’ve always been a system leader, if
not I can’t do my job internally it’s always a very externally facing role. But the work in
The Institute has helped strengthen those relationships and the understanding of where
are the people and organisations and ... in working with them” (R16).
Respondents such as R19 believe that LIQH is the correct forum “for clinical debate”
with a view to bringing about systems-wide change (R19), whilst R10 believes that the
range of people would not have come together under one banner if there hadn’t been an
Institute: “They may have all been at an event somewhere, but not in any way having
that level of depth of conversation and exposure. And there’s something quite levelling
about it”. R17 sees the LIQH as an opportunity for putting Leeds and Yorkshire &
Humber on the national map i.e. for creating the first whole place based network:
“…there’s a whole community that feels as though we’re in the naughty corner, where
health and social care is concerned. So actually, [we want to be] the place that people
talk about for positive reasons, rather than seeing us as some sort of problem child. It
was quite important to me, really”. In a similar vein, R19 seen a real need for such a
forum whether it’s LIQH or something else:
“...it’s helpful to have The Institute driving that approach. I think it’s an approach that the
NHS should take, no matter […] whether The Institute was there or not. I think it should
be putting clinicians at the forefront, I think we should be spending more time to involve
clinicians – patients in discussions and decisions that are made about them. For
instance, conversation needs to be with them, so I think we should do that anyway”.
Shared Narrative
Interview responses exist along a continuum from ‘it’s already here’; ‘it’s almost ready’;
‘it’s nowhere near ready’. Some suggest that perhaps a shared narrative should have
been sorted out both at the beginning and also allowed to evolve through the journey.
Most respondents shared their feelings about the shared narrative and the role that the
LIQH should play in its development. For instance it was reported that the LIQH should
be a facilitator of the network rather than as a leading narrative. It shouldn’t be defining
what should be in the narrative but only to facilitate the process:
“I think The Institute’s contribution to the city’s narrative is that the city is trying to have a
narrative, but really The Institute should not be leading that narrative it should be
contributing to the narrative coming out from the wellbeing board and the joint health and
wellbeing strategy, the organisations, those organisations are trying to get a collective
narrative, and The Institute contribute to it, it shouldn’t be leading it” (R11).
The implications of a joint narrative have permeated through interview responses. A
continuum exists between those that felt a shared narrative doesn’t yet exist; those that
feel it’s partially developed or those who see it as even fully developed. R7 was

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confused because he presumed that the shared narrative was already agreed: “I think
we’ve got one about common language, common training, common approach to putting
data at the centre of what we do, common approach to reducing unnecessary variation
and a common approach to doing that in partnership with our patients. That’s it” (R7).
R20-stated how “...in our group we’ve got GPs, consultants, people from different CCGs
across the city, but you have a common aim and a common language, and I think it
helps to break down barriers” (R20). LIQH are helping to influence behaviours through
the use of language “I see people start to use the words – I certainly see people using
different language regarding, say, ‘The problem is’, then they say what the problem is.
What we start to talk about now is, they say, ‘The hypothesis that I’m working on is that
too many people are’, and then they insert, and then we go away with the data to try and
prove or disprove that” (R21)
Others see the value in a shared narrative but accept that it will take time to develop i.e.
“That’s the key thing. And probably from my perspective actually now is a good time to
pull something together and we can do it reasonably quickly [3 months]...It depends on
how you define a shared narrative”. Perhaps LIQH members / participants already have
more of a shared narrative than they realise, but it was reported that some people want
a hard tangible i.e. “a set of slides to take back into their organisation and say this is the
institute but I think it is sort of good to move forward and then just do some checking
back” (R3). There was a real desire to keep pushing and energizing and “I did find the
approach and energy and drive quiet refreshing” (R3).
A shared narrative was reportedly raised as part of the APL but some respondents felt
reluctant to reduce it to i.e. a set of sentences, but accepted that it must be reflective of
people’s needs. However the complexity of developing a holistic and shared language
was notable through some respondents with only a fleeting input compared to others i.e.
from the medical senate who look to Utah as a yardstick: “So again it is difficult to make
sure that everybody is on the same page” (R3). R5 felt that is a shared narrative had
emerged from day one of the ALPs, “I can guarantee that by the end of the course we’d
have to revise it”.
However rather than a shared language, a common shared wordage for universal
conversations by LIQH stakeholders would be useful: “So that it’s almost a script that
these are the things that whatever we get the conversation we get these in. Clearly there
will be a spin on it from my spin or their spin or whoever but at least it would be useful to
have some core elements that we all signed up to and shared” (R5).
This links back to the notion of having a shared agenda rather than simply another
shared organisation per se.
Perhaps a shared narrative should have been partially concretised both at the beginning
and also allowed to evolve through the journey.
Narrative emergence is key and should not be forced upon new participants. The novelty
of LIQH and the recognition issue (of being part of LIQH) will enrich the narrative
because it’s their story: “It is something that as a system we have created with the
university and with various other people...because we want to improve quality and I don’t
think that has been very clear” (R6).
Perhaps the current intake should be aware from the outset of their responsibility to
create (and for later intakes, to recreate) the narrative i.e. by setting their parameters
rather than focus on a fixed narrative: “There are roughly a 120 people roughly going
through all the leadership programmes through LIQH, how do we capture a little bit from
each of them to become the narrative for next year” (R6). This suggests the need to

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change the current intakes immediate perceptions of viewing it from a pre-defined,
solution-based mentality: “So there is a bit about how it has been described to people,
what the differences are and think there has been real mismatch actually about how we
have described it across the system” (R6).
A spin off from the Programme is also the spreading of a shared language back at the
workplace. R20 noted how “We sit and talk, you develop a language, don’t you, and
that’s been quite reassuring, and I think what we’ve recognised in our organisation is we
want to come together and share that broad LANGUAGE with other people who haven’t
been through the programme or aren’t going through the programme, so we can all
become stronger and be allies, like a community practice together” (R20).
Some respondents inferred that LIQH’s strategy is clear but there was immense difficulty
operationalising it:
“I think the work that we’ve done and also the people, like the chief executives of the city,
have participated, I think that’s really good actually, because I do think we have kind of a
good description of what the end product looks like. What we’re struggling with is the
means to the end, actually. But at least we’ve got the end statement, which we never
had before in terms of our aspirations for the city as a whole. So we’ve got that. What we
now need to do is the really difficult means stuff in order to deliver that end statement.
But I think it’s really good that we’ve got one because we didn’t have one before”.
Observers such as R16 did not think that a shared narrative could have been developed
at the beginning of the ALP, but would be deeply saddened if the LIQH wasn’t supported
or had its momentum stalled by internal politics i.e. within the university.
OVERALL SCORES
What is significant in this is that the current scoring differs from the baseline in both an
improved average score, but more importantly less diversity of views in terms of the
scoring with one outlier
Baseline views

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Current views

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LEADERSHIP ACTIVITIES EMBRACE COMMON GOALS AND ALIGN
ACTIVITIES THROUGHOUT THE SYSTEM/ NETWORK OF CARE
“THE THING WHAT I HAVE PERSONALLY GOT OUT OF IT IS THE FANTASTIC CO-OPERATION
THAT HAS BEEN SHOWN BY ALL THE ORGANISATIONS IN THE CITY, AND THAT WILLINGNESS TO
WORK TOGETHER, WHICH I THINK IS REFRESHING AND IS REALLY GOOD FOR PATIENTS. I
THINK IT HAS REALLY HELPED ME TO SELL THE MESSAGE TO CLINICIANS WITHIN OUR
ORGANISATION AND HELPED THEM TO SEE – HELPED ME TO HELP THEM TO SEE – THAT WE’RE
JUST A VERY SMALL PART OF THE PATIENT PATHWAY, AND NOT – SOMETIMES, PARTICULARLY
WHEN YOU’RE IN AN ACUTE, YOU FEEL LIKE YOU’RE DELIVERING THE WHOLE OF THAT
PATIENT CARE”
In terms of leadership in a collaborative, there are two elements, the role of leadership
and the role of a leader. The LIQH literature review found that the ability to create a
vision for innovation and translate that vision into strategy is essential, and co-ordination
between both policy and operational spheres is critical for supporting the implementation
of intricate innovations at large scale.
SYSTEMS LEADERSHIP
Evidence from the literature review infers that for most high performing healthcare
systems globally, not only is shared and distributed leadership required, but there should
also be strong senior leadership. This was evident through a range of responses in the
current study. Respondents implicitly referred to being in the same boat and how they
must row together or sink. This was evident around garnering acceptance that pathway
work is a longer term commitment and should be supported as such. This reportedly
leads to hesitancy amongst the tops and issues have arisen regarding how committed
senior leaders actually are. A lack of support permeates to unease and despondency
amongst innovative and keen subordinates. Also power and politics are at play from
senior leaders to frontline teams and subordinates can be hesitant to discuss sensitive
issues with peers. Senior leaders were seemingly expecting frontline teams to be
discussing things without fear or fervour. This in turn is equated with a change
management perspective, where there is a need to break the “cultural cycle” of where
top and bottom are not working or conversing, together (R14):
“And so you’ve got a sort of tops, middles, bottoms, so all the people in the PLP are
equivalent bottoms, so it’s real group thinking full of…sort of in it together, [but] the tops
SUMMARY
Respondents
 Recognised the significant role individual leadership has played in securing the
pace of LIQH work, and the need for succession planning.
 Were committed to LIQH as neutral space for coordinating and securing change.
 Identified concerns about the commitment of senior leaders; and the need to
engage more clinical directors in the LIQH programmes.
 Valued the relationships generated between the voluntary and community sector
and the public sector and the opportunities that has created.
 Reported the tensions between LIQH system wide work and the day-to-day
challenges of leadership in their own organisations.

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are out to get us...What do we need? We need the tops to pay real attention to the
bottoms. So when a chief exec says, ‘It’s not going to [provide] any outcomes for me,
you are not talking to any of the people on your Professional Leadership Programme
what they need from you in order to save money. You know, you go in circles…, but…I
think it will, absolutely think it will. No doubt about it, I wouldn’t be doing it if I didn’t think
it would solve the NHS’s problems. Will it do it in the next two weeks? No” (R14).
The present study correlates with the LIQH scoping review finding that leadership of
improvement collaboratives is the most important variable in operating or sustaining any
collaborative venture.
Regarding resistance to change, people are highlighting tensions within the health
system’s support for LIQH for instance around ‘backfill’, but noted the fact that people
are finding a way round this in order to participate. This is seen as a positive
development because it means that people care about their work in LIQH and want to do
it well. Going forward for many observers, there is a need to persuade more clinical
directors to engage in either the APLP or PLP. These leaders would have the ability to
effect change. Respondents voiced the need for finance and senior corporate people to
be represented:
“... the challenge for us is if the execs of our organisation don’t do this. Don’t go through
this programme either they’re going to trust us to say it’s the right thing we’re going to do
or they’re going to be a major block. Getting execs to go to a 10 day course is
impossible. And actually if I look at the APLP, 10 days was far too long. We started to
repeat ourselves... And I know it was 20 days at intermountain ... but I do think if you are
going to do a 10 day course you have to have a certificate at the end of it.... Or you
shorten it and you focus it and the more senior people [as] they have the more
insight...None of this is particularly rocket science. Most Doctors understand statistics
and QI and some of those methodological pieces” (R4).
A number of respondents referred to the utmost need and importance of LIQH but
complexity and tensions within own organisations are causing some concern; “…it’s a
really useful idea to have a kind of co-ordinating centre for improvement activities, who
not only co-ordinate but also does things. So I think that’s really useful as a concept and
I’m a great supporter of that. And therefore, that’s why I am broadly speaking a
supporter of The Institute, but I suppose the thing I struggle with is that the specifics of
my organisation, the work settings in which I work, is that it’s not all that simple to me”
(R17).
Voluntary and Community Sector engagement
In the present study, the importance of engaging in and understanding holistic and
citywide thinking has opened access for the Voluntary and Community Sector (VCS) to
new opportunities and i.e.
“…made it easier to then go out and speak to all of the CCGs... we’ve been raising the
need to have resources shifted through grants into the sector. So we’ve been quite
formally making proposals around the third sector, and grant programmes that would
support and develop some of the thinking, and it’s been really useful from that point of
view” (R10).
However, issues have arisen about the VCS’ capacity to embed itself within the context
of the three Clinical Priorities i.e. in terms of its relevance and relationships amongst
other things.

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It was evident that attitudes and behaviours around leadership and to some extent
decision making have changed for many participants as a result of their own contact with
LIQH: i.e:
“...it’s complicated about leadership in a flat sector where you don’t have the hierarchies,
and I think it contrasts hugely, [with] health organisations where there’s a massively tall
and graduated hierarchy of people’s roles and positions, but I think, because the third
sector’s a very different beast really, then that’s a big issue, and I think it’s given me the
opportunity to think about and understand and unpick some of those” (R10).
The act of decision making is highly complicated for many participants, and it’s almost
impossible to click fingers and immediately make things happen. Rather, the impact for,
for instance participants from the VCS lies more in development of relationships and
feeding information and having conversations that invariably impact on decisions made.
However, it was reported that LIQH is acting as a facilitator for the VCS to exploit some
significant opportunities made available in the neutral spaces.
THE ROLE OF THE STRATEGIC LEADER
LIQH’s scoping review reported that it takes an extraordinary leader(s) to move this type
of entity forward and to generate buy-in (consensus) required from all participants.
Becky was seen as the catalyst for both driving the LIQH strategy at a higher contextual
level, but also for ensuring grassroots and patient/service user involvement was
diligently embedded. Becky was widely credited for creating the momentum and
providing the necessary push to keep striving and focusing on the bigger picture,
particularly when challenges emerge. This also equates with the R1’s assertion for the
need for a systematic leader that recognises variations in performances and can
address and reconfigure them for transformational changes. The role of the strategic
leader in collaborative and also succession planning for that leader is very important.
Some respondents inferred that what was particularly special about LIQH and the virtues
that are associated with The Institute is the strategic leadership provided by Becky. R11
believes “.... having someone like Becky’s drive and enthusiasm is very important.” “...I
think it is just to re-emphasise the leadership that Becky produces and provides. It’s very
important to have that driving us forward, and I think that …we shouldn’t underestimate
that as a characteristic of The Institute” (R11). However one respondent raised the issue
of Becky seemingly being too much in charge and the need possibly to bring in or share
this leader role with a clinician as they have in Intermountain: “I think a significant
clinician. We think we’ve probably found one as well, not to necessarily put into that very
pivotal role, but – or not immediately anyway – but I think we recognise that there will
need to be a clinician who will help to drive this, not just the people who are keen to say
but have got another day job” (R12).

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OVERALL SCORES
The current scoring differs from the baseline in an improved average score and more
uniformity in scoring with two low scores. F being the constant outlier in the second
survey.
Baseline views
Current views

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CLINICAL LEADERSHIP IS SUPPORTED BY PROFESSIONAL
MANAGEMENT
“…FOR ME – WE COULD BE WRONG, BUT FOR ME IT FEELS LIKE THIS HAS GOT FRONT LINE
COMMISSIONERS WORKING TOGETHER IN A WAY THAT NOTHING ELSE HAS IN THE CITY TO
DATE.”
The Institute is seen as an enabling mechanism for many individuals within healthcare
organisations. R1 stated that: “the institute has had such an empowering effect on him
that this has filtered through to his subordinates in the workplace”. Passive stakeholders
will not push the agenda, and it is only being active that these higher level agendas can
be pushed. “This is a partnership between people who are interested and want to do
something differently in their workplace, and how we resolve that, but they have to also
be active players in it” (R14). Respondents see another level of strategic importance in
terms of training senior leaders in the health and social care economy in Leeds to
understand quality improvement methodology and attempting to achieve effective
continuous improvements in the quality of care: “...we know that there are big faults in
the way we deliver healthcare, particularly around primary care, and we know that things
don’t work well; ...I think these sessions will not necessarily change the way that
individual organisations work, but will change the way that we work together” (R15).
Respondents clearly viewed the programmes in a very positive light for illuminating
quality improvement amongst Leeds professionals.
THE RELATIONSHIP BETWEEN THE SYSTEMS LEADERSHIP PROGRAMME PARTICIPANTS
(APLP) AND THE CLINICAL PRIORITY PARTICIPANTS (PLP)
A platform now exists for PLP participants to have their voice heard. It was also reported
that APLP members act as system un-blockers i.e. have the influence to drive through
change proposed by PLP participants, who normally wouldn't have the power
(subsequent empowerment):
SUMMARY
Respondents
 Widely reported the empowering effect of LIQH on themselves and the people
they work with
 Identified that LIQH is creating the conditions for a dispersed model of
leadership to work, and fostering a culture of learning across organisations
 Valued the role of leaders who are part of the Advanced programme acting as
un-blockers to those leading change in the clinical priorities; and acting as
mentors and buddies
 Valued the resource from LIQH to support improvement and teamwork
enabling the teams to do really good work together across the system
 Recognised the increased cooperation of member organisations over this
year, particularly social care
 Have changed their perspective to a ‘whole pathway’ view rather than a partial
‘my area’ view.

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“If people on a PLP say what would be really helpful is if the data that comes out [of]
LTHT on attendances, people turning up with atrial fibrillation if they could be reported in
this way rather than the way they currently are, that would be really helpful but there’s
nobody on our PLP who has the power to make that happen. But if they bring that to me
and I can speak to our finance director or the finance director at LTHT or whoever it is,
it’s then my job. I can sort that out. To then work out how do we implement that change
that has been recommended on the front line” (R7).
R7 referred to LIQHs ability through its programmes relating to i.e. buddying between
ALPs and PLPs as: “...creating the conditions for an empowered dispersed leadership
model to work. So they’re escalating a problem to me that they can’t solve that I then
have the ability to just work out and if I don’t know how to do it then I know who to ask to
do it for me”.
R13 reported contact being made after PLP leadership development sessions between
herself and the senior person in her organisation undertaking the ALP. Although the
contact occurred once, it was sufficient and effective: “She knew about driver diagrams. I
can’t quite understand what’s the difference between the two because they seem to be
doing exactly what we’re doing but, hey ho. And then our programme manager, she was
there as well, and Helen and I were showing her how to do it, so. So she learnt it” (R13).
It was reported that the APLP is providing a support base after the programme
concludes and enables participants to help one another even though they may be from
completely different organisations: “it’s given us this common set of language and
information, I guess, that helps us to […] to call on the other people that were doing the
Advanced Leadership Programme, to help us with some of the work” (R20).
A PROFESSIONAL CULTURE OF TEAMWORK, ACCOUNTABILITY, AND IMPROVEMENT
A key feature of high performing healthcare systems is professional culture building that
facilitates quality improvement, patient engagement and teamwork. Bringing changes at
micro system level underpinned by local support was reported, and this support is the
development of themes and strong leadership in a culture of learning and engagement
which augurs well to continuous healthcare improvement. This is a view held by most
respondents, for instance R1 who believes LIQH is “helping to foster a culture of learning
across organisations”.
Language
The LIQH programmes were seen to reinforce the use of tools and common language in
decision making for all: R4 stated:
“I think behavioural change is the language I use. Examples would be that I talk about
continuous improvement all the time. I talk about information not data, information for
and I really like the phrase, ‘information for action’, I really do. Information. I talk about
the way beginnings change, the way we present information so that it’s more SPC
charted. We can see trends. We can see the issue and I’m using that language with
anybody I talk to”.
Shared methodologies
It was reported that methodologies such as PDSA were already recognized and
understood by several respondents but LIQH helped to bring these back to front of one’s
mind: “…it does remind you that you know about those things; ...we did come back and
draw a driver diagram straightaway. So it was useful and we did use it” (R13).
LIQH has had clear impact from its data analytics team:

26. STRATEGY 2014-2020
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Working together across the system
Good relationship building has taken place as a result of LIQH, “So the QI team at
LTHT … are coming out to primary care to see what we are doing. So it became
apparent that non clinicians have no understanding of what goes on outside of their
organisation” (R6).
Also the fact that top people in the city have taken time to participate, but now that they
are engaging, it is seen as a positive development. Council engagement by three key
members, albeit belatedly, in the recent Fractured Neck of Femur workshop had a really
positive impact on participants as it was the first time that the Council become properly
involved: “I think we’re still putting – we’re still getting the right people in the room, we’re
still getting the commitment we need in order to make this happen” (R14).
Several respondents personally highlighted significant levels of co-operation that is
being shown by a range of key organisations in Leeds. R12 referred to it was a
“willingness to work together, which I think is refreshing and is really good for patients. I
think it has really helped me to sell the message to clinicians within our organisation and
helped them to see – helped me to help them to see – that we’re just a very small part of
the patient pathway, and not – sometimes, particularly when you’re in an acute, you feel
like you’re delivering the whole of that patient care” (R12)
In one of our PLPs there is a consultant surgeon who has his heart set upon the idea of a rapid
access clinic. So, what that means is that about eight hundred to nine hundred people every
month, turn up to hospital in Leeds, with a problem, and his wanted solution to create a rapid
access mechanism because these people are waiting too long for his precious services and they
potentially are getting iller while waiting, or perhaps die, or at least have anxiety because they’re
worried they might have something wrong with them, so his solution to that was, ‘Let’s create a
rapid access clinic’. Now, when we started to look at the primary care data we started to look at
where these people had come from and the reasons why, a third of those people didn’t have that
cardiac problem that they were there for, which meant actually that of that nine hundred people,
only six hundred needed to be there. Three hundred may have had nothing wrong with them, or
something else... so they were unnecessary demand. So actually, he wanted to create a rapid
access clinic to cope with the nine hundred people, whereas actually what we needed to do is to
say, ‘Well, look here, if those nine hundred people turn into six hundred people, would the system
you’ve got now be rapid access?’ and the answer is, ‘Well, yeah’. So actually, if we reduce the
flow upstream of people getting to him... the rapid access clinic would have got funding and those
sort of things” (R21)

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OVERALL SCORES
The current scoring differs from the baseline in an improved average score from 6 to 7
with no score this time below 6 (original ranged from 3.5 to 8)
Baseline views
Current views

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SHARED DECISION-MAKING WITH PATIENTS AND FAMILIES
“I FOUND THAT [CO – PRODUCTION WORK] INSPIRING. ... IT WAS NEW AND IT WAS FRESH AND
WE TESTED AND OF COURSE WE NEED TO DO THAT AGAIN”.
The tools and frameworks used in the teaching are having a significant effect on
participants traditionally used to more complicated technical tools and techniques. These
are seen as a more practical and simple means for undertaking their work. A key take-
away from the programme was a large appetite for coproduction and the embedding of
coproduction tools and techniques within organisational settings. R1 hasn’t been deeply
involved with the development of LIQH, yet acknowledges that in terms of understanding
the need to coproduce solutions, “LIQH has probably just reinforced a view that had
evolved over a period of time anyway” (R1, 2014). R2 reported how, within an
organisation of fifteen thousand people, he was constantly coproducing but this occurs
internally in regards to managing people who work within those services (managing out-
patients and managing theatres).
Enthusiasts
R19 seen real value in the institute for leading GPs to open a deeper discussion with
patients to really get to the heart of their needs: “... by encouraging the GPs to have
those conversations with the patients about the right care in the right place at the right
time, rather than this very ‘Can I have a hip replacement?...and I’ve got the budget, it
does because I’ve spent four/five thousand pounds on someone that maybe doesn’t
necessarily need it right at that minute” (R19).
R6 sees great value in going out into the community, engaging and then feeding back
knowledge and insights, “...it’s quite basically, wow you’re changing your behaviour as a
result of that. You’re trying to change your practices behaviour as a result of that. It’s a
drop in the ocean if we’re honest but that drop could become bigger. But you just have to
keep supporting it otherwise people stop”.
Concerns
Conversely, respondents such as R19 question whether patient involvement is always
such a good thing. It was reported that:
SUMMARY
Respondents
 Found the coproduction work inspiring and reported a real appetite for
coproduction approaches, as well as identifying the power of their experience in
trying these approaches out in practice ‘it’s one of the big ticket items’
 Are struggling in some instances between the priorities of patient groups and
wider communities
 Recognise this is one of the more difficult areas to work on as it’s so different
from the way they have been working so might take longer than other elements
of LIQH work.
With some noting that it is part of a wider movement in the city not confined to LIQH

29. STRATEGY 2014-2020
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“So we’ve got some whole bizarre cultures around, you know. So I want to close down
the A&E hospital, we’ve got seven A&E hospitals in Leeds that you can walk in, we don’t
need seven of these, we can’t afford to run them, shut one. I have to ask patients, ‘Is it
all right if I close it?’, well of course it’s not all right if you shut it. Am I really going to say
yes? Don’t be so ridiculous. So why ask them? In Spain, the Spanish healthcare, what
do patients know about it?”
There are seemingly too many demands from public, patients and the media which can
lead to a conflict of interests:
“Touch wood, I’m relatively well, so I don’t know I’ve particularly got a view about what’s
more important in terms of healthcare, apart from I feel a bit bereaved at the moment, so
having somebody to help me with that bereavement might not be a bad idea, I don’t
know. But it’s all very individual... I don’t know that the NHS can cope with all of that. It
can’t cope with all those demands, which is why from an Institute perspective we’ve only
focused on three things, and in terms of the Utah experience they only focused on seven
R15 has mixed views on the Co-Production theme in that patient input should be very
carefully considered because of their lack of pathway knowledge and fear of becoming
institutionalised:
“ I think the co-production of having patients actually involved at the beginning, telling us
what the problems are and helping us come up with the solutions is a fantastic idea, and
is something that I would certainly like to do more of in our organisation in future...But
you talk about adaptive, I mean, this new way of working that The Institute’s pushing at
the moment, their idea of co-production and distributed and collective leadership, shared
decision-making and professional inter-organisational working, I know that one of the
criticisms about quality improvement drives in any organisation or any system is that it
normally stems out of the desire or a need to address a specific issue, some are more or
less successful than others” (R15).
Quality improvement was referred to as an all-encompassing involvement of patient,
administrators and medical practitioners (R7), and whilst R16 is bringing her learning
from the LIQH to the workplace around distributed and shared leadership, she was
sceptical about coproduction. The concept was fine in theory but difficult to
operationalise in practice: “how to do it in reality, with the timescales that we’ve got with
work [and to do this] in a meaningful way, is a challenge”. R8 believes that it has
enabled her to understand the ‘whole’ better, and to understand the importance of
shared decision-making. It has also enabled senior managers to buy into key concepts
and get more up to speed on LIQHs methodologies. R8 has been much value in
understanding the concept and practicalities of coproduction, and feels that there’s a
time and place for patient/service user/carer involvement:
“I think it’s been helpful in terms of just reminding, helping people to think through so
many differences between consultation, co-design, co-delivery; [some participants are]
extremely good at consultation and none are very good at co-production and co-delivery”.
Others were very optimistic about the potential of coproduction: “ I think co-producing is
one of the big ticket items that you can tick. I think, historically, we’ve been very bad at
that, ... we’ve not trusted people. ... I think letting go of control to make a decision is one
of the great things The Institute can do, and I think the evidence is it’s worked very well. I
mean, it’s super for some things and not for others, obviously, but in the appropriate
conditions, why not? I mean, who are the experts, the experts are the people”

30. STRATEGY 2014-2020
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Mental health
Mental health and learning disabilities are seen as far more advanced in coproduction i.e.
that Acute Care, but any self-congratulation is very premature and foolish. This ties in
with the code on doing something differently, however a clear issue has arisen in
regards to the involvement of service users i.e. in a consultation capacity of informing (of
a service change) capacity.
“I think the danger for mental health and learning disabilities is that they think they have
this one absolutely cracked. Because the difference between ourselves working in
mental health and learning disabilities and say acute care is that we would like to think
that the patent is absolutely at the centre of everything we do and that coproduction is
our bye word. I would certainly hold that we are a lot further ahead on this than our
colleagues in acute care and primary care so in this coproduction of care plans,
treatment plans whatever you want to call them and negotiation about what the goals of
our interventions and the contracting around that. I think that’s a fact. [Also]...I was at a
service user meeting and was questioned [that] because we have service users on our
appointment panel and we have service users when we do changes to services etc and I
think what we have to be very clear on is, are we consulting or are we informing?” (R5)
This will be a key consideration for stakeholders from mental health and learning
disabilities. R6 stated: “I have supported some GPs that are going through co production
work. A couple of them are beginning to realise, actually there are people out there that
can help us make our lives easier but easier in the sense of, we can get on with the bit
that we are good at doing i.e. dealing with the medical problems where people need
fixing. But then there is the more superficial stuff where people do need fixing that we’re
not good at doing and there are other people that can help support us. And again you
don’t know who’s out there to help” (R6).
Doing it already
However, Co-production is old hat to R17. His sector is much more advanced than the
acute sector:
“...in Leeds we actually co-provide a significant number of our services anyway already
with the voluntary and the third sector. So some of the principles in and around co-
production is kind of not new to us and even old hat, to be honest with you, because –
but I think that’s something about how mental health services and learning disability
services have evolved over time, ‘cos I think we are much, much, further ahead about
the kind of people that engage with us in our day-to-day work and what we want to do for
the future, I think we’re much further ahead than the acute sector, I really do believe that,
there are loads of examples I could point to in that department.”
Co-Production impacts are reportedly happening outside of/regardless of LIQH: R17
redesigned community health services from twelve teams to three localities and thus:
“...we don’t need the same types of infrastructures or depth of infrastructures...what we
did was involve quite a large group of people providing services as well as people
receiving services. And actually, and also, not only did they yield significant efficiencies
for us, but also actually drove our significant savings actually”.

31. STRATEGY 2014-2020
30
OVERALL SCORES
The current average score isn’t very different from the baseline although there is more
uniformity of scoring. One respondent reported that her scoring was lower because at
the baseline she thought she knew what this meant, but now she has a much better
understanding of what it means
Baseline Views
Current views

32. STRATEGY 2014-2020
31
EVIDENCE OF WIDER IMPACT
“LOVE THEM (PLPS). IT WAS AN ABSOLUTE EYE OPENER BECAUSE IN TERMS OF QUALITY
IMPROVEMENT I’VE NEVER CONSIDERED IT. ………AND YOU JUST SEE THE POTENTIAL FOR
WHERE IT CAN REALLY INFORM, NOT JUST THAT PROGRAMME BUT OTHER ELEMENTS OF
YOUR WORK. SO REALLY VALID”
PROFESSIONAL LEADERSHIP PROGRAMMES9
Up to date reports of the progress of the PLP Change work is provided in the Annual
report (see Appendix 2) and a full report will be undertaken at the end of Year 1 of each
PLP. However there was data from the interviews which is presented here.
The present study finds that it is perhaps too early to be seeing significant impact,
however there are important instances of impact and learning which are worthy of note.
LIQH are unearthing real insights that were otherwise invisible i.e. in regards to
Cardiology Outpatients’ Reorganisation where it was reported that GP change was
required rather than more cardiologists. Hence rather than a structural solution, LIQH
are facilitating conversations between Consultants and GPs in order to identify the
underlying causes and seek ways to address it: “A very different order of problem. So, I
think that we’ve both begun to understand what the raw problems are and set the
relationship in place in order to handle professionally those real problems”(R14).
APPLYING LEARNING OUTSIDE LIQH PATHWAYS
System changes
It was reported that small systems wide improvements are the overarching objective of
the LIQH. While they might not immediately result in change to the pathways, there are
other micro-level changes in their regular practice that impact positively upon patients i.e.
“Now, in the advanced programme, their ability to get seven-day working is a result of
the learning they had done on the [ALP] programme” (R14).
9
Impact from the professional leadership programmes was reported in the Annual Report and that
section is reproduced in Appendix 2
SUMMARY
This augments reporting of impact in the LIQH Annual Report 2015
Additional impact from LIQH outside of the clinical priorities includes:
 New insights into longstanding problems
 Improvements outside LIQH as a direct result of relationships developed
(e.g. between the VCS and NHS; between GPs and Secondary care; across
primary care) or acquisition of techniques and skills (e.g. using driver
diagrams to improve flow in a Practice)
 Changing individual’s leadership of their teams outside LIQH
 Generating more inter professional working
 Changing specific service (e.g. in community pharmacy)
 Widening leadership – with people involved in LIQH taking on wider
leadership interests

33. STRATEGY 2014-2020
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New relationships
As a result of the programme, inter-organisational working is occurring between VCS
members such as R10 and GPs, and also between R10 and Leeds Community
Healthcare to discuss quality improvement and the third sector: “So, definitely some of
those relationships that developed have enabled other conversations and other things to
– you know, work to be done and links to be”. It was reported that learning is being
applied in different ways.
R18 is using learning from the LIQH to plan for the future i.e. by using methodologies
and embedding some of the insights around leadership, facilitation and communication:
“I’ve been using it in my own practice because we moved from we changed our policies
and we’ve been using driver diagrams and charts to try and improve the flow through our
practice” ... “I’ve had/I’m having communications with the medical directors and LTHT,
about programmes. I’m sponsoring and attending one of the PLPs as well to try and get
some support... it’s very early really, it’s more what I’m thinking about doing rather than
what I’m doing”
It was reported that LIQH programmes have had an impact in regards to QI strategies
and processes within the VCS:
“One of the things we do is we give out hundreds of grants. We gave out four hundred
odd different grants to two hundred odd organisations last year. So part of what we do is
sort of monitoring impact and performance and stuff as a result of that, and I think… it’s
definitely thrown up a lot of things for me to think about in terms of understanding all of
that and the context, and how we use that and how we kind of measure and look at all of
that data and use it” (R10).
R10 is reportedly having follow-up conversations with QI professionals from the LIQH
programme to support its application within the VCS and in general had a really positive
experience on-board the programme: “for me personally it’s been really interesting and
useful, and I’ve learnt loads of stuff about … quality improvement and data, so definitely
there’s been a lot of personal learning around that. There’s been some quite challenging
stuff about sort of the dynamics and processes, but I think it’s been really good because
of that”. R9 and his line manager who works on the ALP reportedly have the will to enact
change; however time constraints with a current large project are hindering R9s attempts
at its application.
Applying the ideas into organisations and teams
R1 reported how the institute has had such an empowering effect on him that this has
filtered through to his subordinates in the workplace. Key members of his organisation
such as director of finance, medical director, and his director of commissioning have all
completed the programme and are currently applying that approach to several pieces of
work that his organisation lead on as a commissioning group. R1 also has a continuing
role of ensuring that those are being supported within the organisation. LIQH
programmes had impacted decision making and some key leaders are implementing it
with much success.
Respondents such as R9 are undertaking more inter-professional working, partially as a
result of the PLP and interaction with LIQH: “because of the groups, it’s kind of forcing
me to where I want to get”.
R9 seen real benefit from some of the programme learning activities that he plans to
apply in his organisational setting at a micro contextual and incremental level:
“…small changes, so looking at your PDSAs, and planning for those, and realising that,
stop looking at the elephant, focus on the small bits, look at the tawny owls, and break it

34. STRATEGY 2014-2020
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down into small manageable chunks. The best thing that we ever did, was that – you
know the game, the potato head, the game”.
Applying ideas to other services
One respondent hopes to use the tools and techniques garnered from the module to
interrogate a raft of service delivery data around community pharmacy services:“...I was
trying to find some patterns from those; around quality improvement. [However due to
backfill]: It’s been difficult to actually sit down and think, right, how will be use this?”
Measurement and standards of success are not very clear in the NHS systems and
LIQH is driving this as previously this was non-existent. “The NHS overall as health
professionals we are not very good at measuring success and we don’t celebrate
success” (R6). There is also acknowledgment that perceptions and expectations are
continuously changing for the better. “I think people’s expectations of the institute is at
very early stages are changing and potentially we’re going to be asking them to deliver
higher than originally where they set out to”(R6).
Reviewing progress
It was reported how the methodology and tools from the LIQH programmes are being
applied in different ways:
“From a personal perspective we are asking our providers but they are already starting
to use SPC charts. With have a quality meeting on a monthly basis with our main
provider, Leeds Teaching Hospital and so they’re starting where they can to use the
SPC charts. And a couple of that sit on that quality meeting are also part of the alp. So I
think we are starting to think about it”( R3).
WIDENING LEADERSHIP
From a leadership and decision making perspective, respondents such as R19 noted
some impact from the LIQH programmes: i.e. “...there’s a couple of individuals who I’ve
noticed who have become much, much, more involved in commissioning leadership than
they would have done before”. There is also a greater understanding of commissioning
as a result of the LIQH and much more clinical involvement in that i.e. in R19s stance
from GPs:
“Commissioning has got a number of parts to it, so be it health needs analysis or
contracting and performance, or evaluation, or planning, or whatever it might be, all the
finances that sit with all of that, so commissioning says all of those things to me”
“I can see it in my GPs that have gone through to do some of this stuff. So I’ve said I
don’t necessarily need to go on this, but I’ve got twenty-nine practices out there, some of
those practices are quite large with maybe ten GPs in them, so there’s quite a few GPs
out there and it’s about doing a bit of talent spotting or whatever on my behalf, so,
‘Actually, you might benefit from this, why don’t you go and give it a whizz?” (R19).
R16 reported that the LIQH programme has influenced her thinking and acting whereby
she now automatically seeks more holistic ways to address health and social care
problems than before and realises the utmost importance of distributed and collective
leadership:
“I have been thinking about ...how much are we doing the bottom up, knowing where the
energy is and just getting started and learning from it, which is the LIQH approach;
rather than a more top down way that I’ve probably worked in the past. [We need to]
understand exactly where the problems and the issues are and work from there” (R16).

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THE IMPACT OF LIQH AS A TECHNOLOGY10 TO GENERATE
IMPROVEMENT IN HEALTH CARE IN LEEDS, IN THIS CONTEXT
“THE NHS HAS IN SOME WAYS GROWN A HUGE PERFORMANCE MANAGEMENT SYSTEM THAT’S
CLOUDED OTHER – ALL IT’S CREATED IS A BLACK CLOUD OVER, I THINK, PROFESSIONAL
DECISION-MAKING, WHICH MEANS PROFESSIONALS HAVEN’T HAD THE SPACE, THE
INVESTMENT, THE TIME, THE TOOLS, THE TECHNIQUES, THE POWER TO MAKE THE RIGHT
DECISIONS….IT’S ABSOLUTELY RIGHT, WHAT WE’VE COPIED IS THE NEED TO SET UP AN
UMBRELLA AS A SORT OF HAVEN WHERE WE CAN EXPERIMENT AROUND FANTASTIC
PROFESSIONAL DECISION-MAKING WITH PATIENTS, ABSOLUTELY RIGHT. YOU HAVE TO DO
THAT OUTSIDE THE CURRENT STRUCTURE BECAUSE THE CURRENT STRUCTURE IS SWAMPING
IT”
EARLY DAYS
To date the LIQH has achieved significant clinical interest, an overarching focus on
quality, deeper integration of providers, but “I think it needs to do a bit more in terms of
where it sits, otherwise – it’s a two-year contract, isn’t it?” (R19). LIQH have successfully
gained senior buy-in across the whole of Leeds’ health economy: “... you can’t do that
from the ground up; they’ve really created an environment that has enabled everyone to
take part in this, in a way that I don’t think any – it couldn’t have been done without that”
(R20).
Rather than develop new systems and processes, respondents such as R16 referred to
small scale changes and improvements brought about as a result of involvement in the
LIQH programmes: “We are being much more conscious about how we’re developing
them and how we are planning, doing, studying and acting, and what methodologies
we’re using for the evaluation and what performance measures that we’re using” (R16).
Results have to be shown; there should be sustainability, particularly support for those
going through the Leadership programme.
10
The collection of techniques, methods and processes used within LIQH
SUMMARY
Respondents
 Recognised the wider role of LIQH beyond pathway work to the deeper
change in the way professional think and act in Leeds, and the systems
leadership required
 Valued the role of the University in creating a neutral, critical, focused,
learning space
 Acknowledged that the longstanding links between the Senate and the
University have contributed to the ability to link theory and practice
 Had confidence in the developments for year 2, building on a groundswell
of enthusiasm, and new skills.
 Were concerned that the model of LIQH as a collaborative doesn’t get lost
into a project contractual mode of working
 Want to create better links between LIQH and external bodies locally.

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Because of the focus on three pathways, there has not been sufficient chance to make
the initiative more encompassing i.e. for everybody to take part in it, “but I think there’s
more people now interested in doing it and going along, it’s got credibility now” (R20).
What should not be lost in translation in all of the narratives is about what LIQH are
about. LIQH is about much more that pathway change and redesign, it also concerns a
deeper change in the way professionals think, operate and work together across Leeds.
Embedded within all of this is the critical function of patient engagement. Combined
together, the LIQH network is a truly unique endeavour that is unparalleled anywhere in
the world at present. The following underpin this reality, because LIQH is:
1. Having a serious conversation across the city where quality is – embedding quality
as a chief priority for the city.
2. Creating transparent costings across primary and secondary care.
3. Unlocking the information governors require so that we can look at variation across
primary and secondary care.
4. Gaining much more/from significant changes in clinical practice that is already taking
place within – as a result of being on the programme, and those are within teams.
5. Generating enthusiasm in clinicians and managers across the system to do
something radically different for patients and service users, and carers, and their
willingness to go over the odds and put time in to do that, over and above their day
job.
6. Taking responsibility! LIQH have got some of the consultants shadowing each other.
The willingness to step into each other’s shoes and solve these problems, whole
system problems, rather than avoid or dismiss them and believe somebody else will
address them.
7. Catalysing a move into Leeds as an accountable system, not a set of accountable
organisations.
There was a degree of confidence that in the second year, LIQH will be more
sophisticated in three ways:
1 ‘One is that we should be able to get data in advance of starting to do the real work;
2 Secondly, I think we’ve got a clearer understanding of the things that need unlocking
at system level; and the things that I thought the quality leaders in the city would get
on and do, they’re clearly not going to.
3 So, what’s really interesting is that the ability of the tops to work as peers, to both
identify and solve some of the issues that need to solve, is still, in my mind, in its
infancy’ (R14).
THE PARTNERHIPS BETWEEN THE NHS, LOCAL AUTHORITY AND THE UNIVERSITY
ENABLING THE DEVELOPMENT OF AN ENABLING SHARED SPACE
The contact between NHS, clinicians and the university has led to a form of balance as a
result of the programme. LIQH is helping clinicians see the bigger picture beyond the
traditional confines of a clinical evidence base. Respondents found the process of
developing the LIQH quite ground-breaking and exciting.
“I’ve been in the NHS for some 30 some years and I think what I found was the
relationship that NHS professional were having with leaders from the university. I find it
quiet refreshing and I found the energy that came from both the NHS professionals but
also from people within the university to move things on at a pace really refreshing” (R3).
LIQH fills the gap in mutuality and trust that traditional bureaucratic (NHS) organisations
often don’t fulfil:

37. STRATEGY 2014-2020
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“...it almost goes down to, if I put a pound down and you put a pound down, even when
it gets really really really tough, you’ve still kept your pound on the table, and even when
it’s really really tough from my end, I’ve not even been tempted to pull out two pence of
that and leave my ninety-eight p on the table. And that takes a lot of trust, a lot of
commitment, from all organisations, and I don’t always see that in the NHS” (R19).
Relationship with the University
There is a real need for a cultural change which can sweep across an entire system.
However this will take time (longer than the five-year period stated for finding the 650m
Transformational Board savings): “it’s part of the puzzle, it needs to be a bigger part of
the puzzle, maybe if we could tie it up with this or tie it up with this, it might be a bigger
part of the puzzle, ‘cos at the moment it feels to be a good thing but it needs to be a
bigger part of the puzzle”. The influence of the LIQHs connection with Leeds University
is more applicable to practitioners on the ground and the institute is incrementally
forming a robust form of business and analytic support i.e.:
“Leeds University’s got a good reputation, so the fact that it is with that is good. The fact
that there are links that could be made into academia is also good for the
project, ……There is also the analytics that come in to support some of that, so we do
reuse the university in terms of that modelling” (R19).
Respondents referred to the conundrum that whilst much enthusiasm for innovation and
change exists within the NHS, it is often lost as potential change agents and innovators
are constrained by governance approaches. LIQH seem to fill this gap i.e. “the design
team through linking with Becky’s team was around let’s move this forward. Let’s not get
hung up on setting meetings up, establishing terms of reference, job descriptions
whatever... Which means where we are now some of that, some of those gaps we need
to go back and filled” (R3). Motivation and momentum is often lost in the NHS as the
goal posts frequently change, leaving those that have worked hard on projects inevitably
despondent. LIQH operates slightly differently within the NHS, due to its inherent
emphasis on the whole system approach:
“The university...always come from an evidence base and within the NHS you come
from the clinical evidence base in the things that you are trying to achieve but in terms of
the tools to get you there you probably don’t understand them. You definitely don’t
understand them. You probably know what the clinical outcomes should be but we don’t
necessarily spend a lot of time on systems and processes that kind of enable us to get
the best outcomes” (R3).
R19 credited with the University for helping to focus minds on that by playing a
facilitating role:
“...and ensuring we don’t go off the rails with those discussions, ensuring that they’re
focused in terms of the three areas that we’re looking at, that we hold ourselves to
account on the delivery of something at the end of those. I think the NHS and local
authority is often very good at talking about stuff or – and we tend to make it more
complicated than it is, but I think, for me, this is about, keep it simple, keep it on the rails,
this is what we’re driving for, etcetera, I think The Institute is good at that” (R19).
Because LIQH are a branch of university they can tap into the expertise of the university
with reduced fees: “So there’s a massive additionally that the university’s bringing in and
they’re not charging for at all, as you wouldn’t because it’s a partnership” (R14).

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The role of the senate
There are three overlapping organisations that are involved in clinical leadership and
management (the Senate, LIQH and CIHM) but they see LIQH as a pivot in terms of
looking at professional standards in the Leeds area:
“So that crosses over with the work of the medical senate and the medical senate
crosses over with the Leeds institute so I think to some extent the role of improvement,
science, change management skills, the role of clinical medical leaders is, that where it
all over laps, all three organisations effectively, senate, LIQH and faculty and medical
leadership and management will have an impact on all of to that” (R7).
The neutrality of meeting grounds adds significant credence to the LIQH attempts at
becoming a high performing healthcare system. There is a broad appreciation that with
the right stakeholders involved in conjunction with stringent and diligent planning, the
other bits will fall into place: “[CIHM have a] willingness to help enact change, and are in
an:
...objective position to say what’s going on out there, what can we do better and to be
the facilitator to bring people together. That’s how I see them...To be with the University
is quite a wholesome thing as well because they hold keys to unlock things” (R2).
Respondents such as R11 believe that LIQH is facilitating the link between theory and
practice. There are strong relationships existing between the institute and senate and
these have developed through the senate over a period of time. Therefore, clinical
leaders have thereby developed relationships and a common view of the system.
However:
‘...relationships and attitude to people has changed very significantly. And whether that
translates to the top tier so-to-speak, I’m not sure that it has because it’s not really had
the opportunity to [do so]. I think there are some key things that need to be sorted out in
terms of inter-professional working around quality and safety and allowed accountability
roles and responsibilities” (R1, 2014).
In regards to comparisons between Senate and Institute and a definition of their different
underpinnings, it was reported that the Senate has a suitable forum itself for issues to
have taken place. R1 stated:
“Why would the senate note have been the right forum for that to have taken place. I
suppose I’m asking what is special the institute in that regard? I think the institute
probably has a more defined work programme doesn’t it really, possibly a bit more
operational than the Senate which is probably a bit more strategic” (R1).
However those involved in LIQH from its initial design, recognise the challenge of trying
to differentiate ownership of the institute.
“The medical senate gave birth to the institute and I think the institute is the doing arm of
the thoughts and processes that would have been talked about in the medical senate. I
don’t think the medical senate had the ability to actually then make those changes but
that’s where it argued for we’re successful at securing funding to invest in the right
people to help spread those messages and deliver that product” (R7).
Clinicians were initially encouraged to meet as a group two and a half years ago but
perhaps they should now be taking ownership of LIQH and speak up about what they
want and what they want to buy: “So that’s what has happened as a result of this.
Because nobody wants to see this stop either. Yes because that would be really
disastrous if this was all to stop now” (R6). R6 also stated how:

39. STRATEGY 2014-2020
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“Previously it was CIHM that provided the senate with work. So it’s almost like you
bought a service from somebody and they provided it and they are pushing to saying are
you going to [take] more of it? Are you going to do more of it? If the buyers, you know
that’s us the clinicians in the room are not really clear, well do we really want to buy it?
And we’re not really sitting down to have that conversation because we are all from
different groups so we really have to sit down first and say ‘what is it we want?”
LIQH’s neutral forum provides a release valve to historical tensions between the nursing
and medical senates: “it was interesting, that journey, because there was some damage,
historical damage, it was animosity, resentment, whatever you call it, in the NHS,
particularly between the professional groups. It’s just, yeah, I think actual distrust, maybe
just a very few of the doctors have too much power, and I think, interestingly, we see
that in more of the providers” (R18). One respondent stated:
“I think the spin-off [of having a strong university underpinning] is going to be a whole
new way of looking at training for people who want to go into this field” (R18).
NEXT STEPS
LIQH will build on the knowledge acquired from understanding the system in which they
are working. That learning is very important in order to make more effective interventions
in the following year. There was much optimism that the plethora or enthusiasm, energy
and dedication to bringing about systemic improvement and comprehensive change can
be built upon and lead to significant changes to the pathways work, and design
improvements from the LIQH’s networked perspective to ensure that it can get up to
speed more quickly.
Respondents such as R20 highlighted the need for developing a community of practice
+ mentoring scheme within LIQH for sustainability purposes:
“I think, developing a community of practice and people that have been through the
programme but supporting them in a way that’s not competitive. So that you don’t feel,
‘Oh look, they’ve done loads and we’ve not done anything’, but in a way that you can
actually share some of the highs and lows of the programme. And I know that they’ve
changed adapted the programme as a result of the things that we’ve experienced, but I
guess it would be good to get together in a supportive way, all the groups together” (R20)
“The first cohort we’ve had, CVD, Fractured Neck of Femur and COPD, and then they’re
having a stake[holder meeting] over in December about the next clinical pathways that
they might want to pursue. So I think it would be good for us to maybe mentor, us that
have gone to this pathway, to maybe support and mentor some of the people that are
going through the – in next year” (R20)
Care should be taken that LIQH is not managed like a project but more as a
collaborative: “I think that whilst we could design a sustainability model that would be
through one of the organisations involved that is not the LIQH, I think it’ll then end up
being project managed as opposed to being supported in the way that I think that
Intermountain supports this project” (R12).
LIQH should avoid “quick fixes” – since the variables around such collaboration and
partnership are multifaceted - and R11 believes that “...the potential strength is around
doctors and the nurses particularly, working together” R11 also believes that “..the
people part of transformational change..” takes time and it is the hard part.
Collaboration is premised under the assumption people have similar objectives and even
if they come from different background and different set of skills – the collaboration could
facilitate shared learning.