Leading change to deliver integrated care

In this section

This section focuses on the attributes of leadership that need to be embedded in successful teams. This is aimed not only at system leaders but at anyone in a leadership role. There are several different models of leadership development, including the NHS national framework Developing people improving care. This includes systems leadership skills for leaders improving local health and care systems, whether through sustainability and transformation partnerships, vanguards or other new care models. These skills help leaders to build trusting relationships, agree shared system goals and collaborate across organisational and professional boundaries. Resources for leadership development are also available through The Leadership Centre and The King’s Fund.

Being visible

Most change fails during the transition from old to new. One crucial factor is that staff in an organisation need to ‘keep believing’ that the change will improve the lives of people who use its services. The leader’s role should not be underestimated in giving staff the confidence to continue. A leader should:

• ensure their role and responsibilities are clear and explicitly shared
• communicate the vision for integrated care widely and regularly across partners and with the population
• show that by pursuing integration, other objectives are achieved as a by-product
• personalise the integration work, so that it resonates with all audiences (including staff, people who use services and the wider public).

Showing resilience

• Leaders should be prepared to take and explain difficult decisions. Many integrated care plans require decisions to be made that can have short-term impact on some organisations. Great leadership will be resilient and find a way through this conundrum to achieve the longer-term prize of integration.
• Working in an integrated way across many organisations has been a challenge for health and care systems. Leaders need to work hard to build trust and a common purpose for integrated care. One successful way to achieve this is by focusing on a particular area of need or priority that resonates across organisations. The improvement of outcomes for frail older people or those at high risk of hospital admission is a good example. The key message from successful systems is that leaders need to be persistent to keep driving forward the vision for service transformation. Organisations where the leadership is seen to have lost interest and moved onto new priorities will quickly lose impetus.

Inspiring shared purpose

• Leaders should be seen to live the values that underpin the local vision for integrated care. They should act as role models for people across your local system.
• It is important to maximise the contribution of the teams to improve the quality of the Better Care work. Workloads should be spread across people who are already stretched.
• A leader needs to demonstrate the importance of Better Care to them, within their organisation and across the local health and care system. This is often overlooked and the role of the leader is to constantly remind people of the Better Care goals to improve population health and wellbeing.

Model: Engaging frontline staff

Lankelly Chase system changers programme

The ideas, experience and commitment of front line professionals are crucial to implementing effective integrated care. Lankelly Chase have run a system changers programme in a variety of public service environments with the aim of enabling frontline workers to contribute to and create systems change. The programme has generated five principles about how this can be done:

1. Create time and space. Frontline workers need time and opportunity to think about how their system is working and how it could be improved.
   Question: Do you offer those in frontline roles time or opportunity to contribute to thinking about how their system is working and how it could be improved? Do people have any space outside of their delivery role? Do you allow people flexibility in their roles to make decisions and changes or do you lock things down in process?
    
2. Disperse power. Give explicit permission to staff to question how your system is working, don’t assume that people will speak up if things aren’t functioning well.
   Question: Are you aware of how power is distributed in your organisation? Do you give explicit permission to staff at all levels to question how your ‘system’ is working with a view to improving it? Do you have genuine feedback loops in place that enable real dialogue rather than bottom-up feedback?
    
3. Take down language and evidence barriers. Break down ‘official language’ and jargon and accept new forms of evidence. This will level the playing field for those wanting to create change.
   Question: Do you communicate in jargon and official language more than you need to? What space and encouragement do you give to voices that speak in nonofficial language or without a cost-benefit analysis? Do you give enough validity to different types of evidence? Are you aware of the labels you use and the impact they have?
    
4. Nurture community. It’s very hard to make change happen alone. Help staff form peer relationships to support each other.
   Question: Do you enable staff to form peer relationships and communities to support each other? Do you encourage interaction beyond people’s official roles?
    
5. Model system change behaviour. Wherever you sit in an organisation, take on some of the ways of being and doing what we’ve just described.
   Question: Do staff at all levels demonstrate system change behaviours? Do they engage with a range of different perspectives? Do they show that it is ok to try and fail when making change to improve things?’ Do they act outside of ‘hierarchies’ or seek to reinforce them?

Source: ‘From where I stand’ How frontline workers can contribute to and create systems change: A report on the 2016 Systems Changers Programme, Lankelly Chase (2017)

Having a grip on the key information

The best metrics for a local system need to align in a meaningful way with the vision and strategy for integrated care. The SCIE Logic Model is a good place to start when confirming how a local system’s various partners and services are intended to work together and clarifying what the system is expected to achieve - from improving people’s experiences of care to delivering better coordinated and more preventative services close to home in local communities. This leadership consensus will then drive local priorities and aid in the selection of relevant metrics. It’s important to consider using a combination of routinely collected data from national sources as well as local indicators.

Leaders should select a small number of measures that act as an ‘acid test’ of local progress in implementing integrated care. The leadership role is to keep the system’s partners focused on a few key metrics, which reflect the goal of organisations working in joined-up ways to achieve better outcomes and experiences for service users. Two examples are the achievement of local Better Care Fund plans in reducing permanent admissions of older people (aged 65 and over) to residential and nursing care homes; and increasing the proportion of older people still at home 91 days after discharge from hospital receiving reablement or rehabilitation services published in the ( National Audit Office 2017).

Measuring effectiveness of health and social care integration

In its Integration and Better Care Fund Policy Framework the Government confirmed its plans to develop a wider integration scorecard – which would combine outcome metrics, user experience and process measures – to help areas understand whether they are meeting its integration ambition, especially at the interface between health and social care.

The Department of Health and Social Care and the Ministry of Housing, Communities and Local Government worked with stakeholders to develop a performance dashboard. The dashboard provides a set of measures indicating how health and social care partners in every local authority area in England are performing at the interface between health and social care. You can find out more at Local area performance metrics.

The Care Quality Commission has produced and is regularly updating Local area data profiles. These profiles give a picture of the health and social care system in each local authority area. They bring together data to give an indication of how different services work together.

Tools and resources

Coaching and peer-to-peer support can help leaders to check their leadership impact and reflect upon and improve their performance.

Tools on leadership style can help people gain insight into the impact of their particular leadership style (e.g. 360 tool provided by the NHS Clinical Commissioners, NHS Providers and ADPH ).

The revolution will be improvised: stories and insights about transforming systems (the ‘Systems Leadership – Local Vision’ programme) draws on insights from 25 multiagency programmes around the country to discuss how people break or make collaboration and service transformation, and what we can learn from their experiences.

The Leadership Qualities Framework (Skills for Care) describes the attitudes and behaviours needed for high quality leadership at all levels across the social care workforce. It focuses on the values and behaviours that provide the foundations for effective leadership in social care.

Checklist for leadership of change

The governance for sign-off and resourcing is clear.

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In my experience it is important to think about outcomes for patients, carers and populations, not targets, cultures not structures, place not organisation, delegation not transfer of functions and clinical and professional engagement.

Andrew Cozens CBE, former Strategic Adviser, Children Adults and Health Services for the Improvement and Development Agency for local government, and President of the Association of Directors of Social Services (ADSS) in 2003/2004