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:
- no one person or organisation can find or organise the solution on their own
- responsibilities are overlapping or unclear
- they need to juggle multiple uncertainties
- resource pressures necessitate a joint approach to managing demand.
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
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
Public service context Open
- Decreasing resources
- Wicked issues
- Regulation and inspection
- Interdependency and interconnectedness
- VUCA volatility, uncertainty, complexity, ambiguity
- Increasing demand
To view a larger version of visual model, download a copy of the full report.
Source of model: Systems leadership: exceptional leadership for exceptional times, The Virtual Staff College (2013)
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
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:
- focusing on outcomes and results rather than processes
- basing the work on strong but honest relationships
- allowing for experimentation – and therefore allowing for risk
- being willing to genuinely listen to others and see their point of view
- being able to adapt, going with ‘good enough’ solutions and building on them rather than waiting until you have the perfect service/solution
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:
- Personal core values (ways of feeling).
- Observations, ‘hearing’ and perceptions (ways of perceiving).
- Cognition, analysis, synthesis (ways of thinking).
- Participatory style (ways of relating).
- Behaviours and actions (ways of doing).
- 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)
Mid-Nottinghamshire’s outcomes framework case study Open
In Mid-Nottinghamshire, commissioners have developed a single outcomes framework to measure improvements in the wellbeing of the population and in system performance. The framework aims to enable providers to work together to deliver a set of common goals and use resources more effectively. It should encourage innovation in how providers deliver services, since it focuses effort on improving outcomes rather than inputs or processes.
Commissioners developed the framework in a working group bringing together representatives of the local authority, local doctors, and Healthwatch. They also carried out engagement activities involving 400 people across Mid-Nottinghamshire. They have focused on developing a set of outcome measures that reflect what is important to people who use services and how services can help them meet their personal goals.
The framework includes four domains: measures of population health such as premature mortality; overall quality of life (including independence and management of conditions); quality of care (including patients’ experience of care); and the effectiveness of care, including immediate and longer-term recovery. The framework includes indicators to allow commissioners to monitor system performance, in particular: to monitor shifts in activity from hospital to the community; to identify areas where activity is decreasing, and allow commissioners to challenge providers if they are restricting access to care; and to measure financial sustainability. It also includes indicators to allow commissioners to monitor how providers are transforming care, such as the proportion of patients with up-to-date care plans or levels of social prescribing as an alternative to medical care. The aim is to avoid setting measures that will overly constrain how providers deliver care.
Commissioners are now aligning contracts with the framework. They are working with providers to agree a baseline of performance and trajectories for improvement, so that they can establish financial incentives linked to the outcome measures.
Source: New care models – Emerging innovations in governance and organisational form, The King’s Fund (2016)