Leading a system to deliver integrated care

Leading across boundaries

Many of the best examples of successful integration in the UK and abroad began with partners developing a shared vision about what they want to achieve and the benefits for local people.

This involves honest conversations about differences and how these can be managed – for example, the ‘soft’ issues of different professional cultures and ways of working as well as the ‘hard’ differences between governance, accountability and financial and performance regimes. A good test of effective joint working is how well partners manage their differences without jeopardising what they are trying to achieve together. This is the essence of systems leadership.

Systems leadership describes the way people need to behave when they face large, complex, difficult and seemingly intractable problems where:

The way forward therefore lies in involving as many people’s energies, ideas, talents and expertise as possible.

Systems leadership is particularly relevant for people involved in the delivery of health and care services, and in integrating complex services around individuals. The aim of systems leadership is to transcend individual organisational interests and work together on the basis of a shared ambition, with a view to making progress towards better health and wellbeing outcomes across a population. It is a practical, grounded approach to integrated working.

This is not to portray systems leadership as some kind of silver bullet or magic wand. But evidence of its benefits is growing and it will be hard to implement effective integration without it.

Whole system transformational change will only occur if we have the right leadership in place. We have found it invaluable to have [systems leadership] mentoring/coaching support for the senior leadership team… Through the Pioneer programme we have had an experienced programme enabler who brings board members together to reflect, share and challenge – we know that if we want to shift the workforce to a new ethos and culture, we need to start at the top.

Clare Henderson, Director of Commissioning, NHS Islington CCG and NHS Haringey

Integrated model

Public service context, systems leadership and systems leaders – an integrated model

Improving outcomes for service users

  • Systems leaders Open

    • Ways of perceiving seeing and hearing
    • Ways of thinking cognition, analysis and synthesis
    • Ways of relating relationships and participation
    • Ways of doing enabling behaviours and actions
    • Ways of being personal qualities
    • Ways of feeling personal core values
  • Systems leadership Open

    • Collective and participatory
    • Shared power
    • Relationship based
    • Influencing and nudging
    • Shared vision and values
    • Focused on product not process
    • Conflicted and contested
    • Disturbs the system
    • Experimental and innovative
    • Distributed
  • Public service context Open

    • Decreasing resources
    • Wicked issues
    • Regulation and inspection
    • Opportunity
    • Paradox
    • Interdependency and interconnectedness
    • Risk
    • VUCA volatility, uncertainty, complexity, ambiguity
    • Increasing demand

To view a larger version of visual model, download a copy of the full report.

Image of model

Source of model: Systems leadership: exceptional leadership for exceptional times, The Virtual Staff College (2013)

Further information

Over the past three years, there has been a national systems leadership programme including a research programme into what makes for good systems leadership; the development of joint leadership development programmes open to people across sectors, and place-based support to some 40 integration and population health projects across the country. The most recent evaluation of these ‘local vision’ projects describes the benefits in most places of developing a systems leadership approach to ‘wicked’ issues, including bringing together stakeholders, engaging professionals and improving services and outcomes for people.

Establishing good relationships is fundamental to joint working and should not be underestimated; listening to others, trust, openess – all need to be nurtured.

Cheshire Local Vision project: developing multi-agency response to social isolation

Shared values

Systems leadership goes beyond partnership or collaboration, because it is not just about retaining the power and authority of an individual leader while working with others. Because of the complexity of the issues involved, systems leadership recognises that leadership is not vested solely in people because of their job titles or authority, and works on the basis that leadership and influence are distributed. It therefore involves being willing to cede leadership to others if they are in the best position to provide it, and coming together not on the basis of a single pre-identified solution, but on the basis of a wider shared ambition or purpose – for example, for a group of people who use services. Systems leadership welcomes partial, clumsy or emergent solutions, and supports experimentation, working with uncertainty and adapting as you go along.

Systems leadership behaviours therefore include:

At the heart of systems leadership in practice are shared values and intentions to improve outcomes for people who use services. This core is surrounded by complex, if interrelated, dimensions. Although they overlap, these dimensions can be categorised as:

  1. Personal core values (ways of feeling).
  2. Observations, ‘hearing’ and perceptions (ways of perceiving).
  3. Cognition, analysis, synthesis (ways of thinking).
  4. Participatory style (ways of relating).
  5. Behaviours and actions (ways of doing).
  6. Personal qualities (an overarching way of being that forms the essence of both professional and personal style and approach).

Systems leadership is best seen as a mindset, or a way of thinking about and approaching the leadership role, rather than a set of technical skills or competencies.

The National Voices website has a helpful summary of Systems leadership for beginners: what it is, how it works, and why it helps.

Checklist: five factors that facilitate effective system leadership

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Source of checklist: Leading across the health and care system - lessons from experience, The King’s Fund (2017)

How to lead and manage better care integration guide
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