System leadership and COVID – Case study of practice

Having completed this research project on the evolving roles of system leadership just prior to the COVID-19 pandemic, Thames Valley and Wessex NHS Leadership Academy and SCIE decided to develop a short case study to complement the main report findings.

This case study begins to explore the impact of the COVID-19 pandemic on the priorities, challenges and behaviours of system leaders. This is not a comprehensive review and the objective of this case study is to start an important conversation about the impact of COVID-19 on system leadership. This case study involved four interviews with a range of system leaders across the Hertfordshire and West Essex Integrated Care System (ICS). The interviews explored the following:

  • The challenging factors for effective system leadership during the COVID-19 pandemic
  • The enabling factors for effective system leadership during the COVID-19 pandemic
  • The behaviours of system leaders highlighted as being most beneficial during the COVID-19 pandemic
  • The positive impact COVID-19 has had on the development of multi-professional, collaborative leadership models and the journey towards integrated care
  • The support and development needs of system leaders that have been accentuated by the COVID-19 pandemic
  • And essential next steps for system leaders following the COVID-19 pandemic.

Participants

  • Dr Jane Halpin, Joint Chief Executive Officer, Herts & West Essex ICS & CCGs
  • Iain MacBeath, Strategic Director Health and Wellbeing, Bradford Council
  • Christine Allen, Chief Executive, West Hertfordshire Hospitals NHS Trust
  • Lance McCarthy, Chief Executive Officer, Princess Alexandra NHS Trust

Challenges

System leaders were asked to reflect on the key challenges for system leadership posed by the COVID-19 pandemic. The following challenges were identified:

  • Guidance and advice from the government and NHS England in relation to COVID-19 has often been belated, contradictory, and not always aligned with the reality on the ground for health and social care organisations.
  • As the COVID-19 pandemic escalated and statutory emergency Local Resilience Forum (LRF) meetings under the Civil Contingencies Act 2004 were called, it led to the ICS being initially split. This is because ICS boundaries do not always align with LRF boundaries. The pandemic also led to regular Integrated Care Partnership (ICP) and ICS meetings being temporarily paused, not least because of the need to attend regular LRF meetings to address the COVID-19 pandemic. This meant that the different ‘Places’ within the ICS were not actively coordinating their response to COVID-19 from the start. System leaders highlighted the need to acknowledge and address the differences in how ICS boundaries have been drawn in relation to other boundaries and the implications of this during an emergency.
  • Not all ICPs within the ICS experienced COVID-19 in the same way. For example, some areas were more rural, while others were home to several commuter towns. This led to crucial differences in how COVID-19 spread. It could feel difficult and lonely for system leaders at Place level when not all areas within an ICS were facing the same challenges or needing to prioritise the same issues.
  • Due to COVID-19, health and care organisations swiftly implemented a formal command and control structure to manage the response to COVID-19. System leaders acknowledged that it could be challenging to adapt one’s leadership style in order to comply with the command and control structure, whilst also trying to maintain a collaborative leadership approach.
  • Health and social care staff are at increased risk of mental health problems with dealing with the challenges of the COVID-19 pandemic. System leaders have had to focus on proactively protecting the mental health and wellbeing of their staff, whilst also having to address their own mental health needs.
  • COVID-19 has inevitably put on hold many of the programmes of work that the ICS and ICPs had on. Momentum has been lost and it will take time and effort to restart this work.
  • The ICPs and the ICS had spent a lot of time gaining a good understanding of the finances across the ICS. A lot of work had been carried out to achieve financial balance across the system. COVID-19 has inevitably disrupted the financial balance that had been achieved – and system leaders will have to start this challenging process again.
  • COVID-19 has highlighted the fragmented nature of the social care sector. System leaders reflected on how local authorities have limited influence on the care market and do not have existing relationships with all care homes. This created challenges for system leaders when trying to respond effectively to Covid-19.
  • System leaders will now have to deal with the backlog of activity that has built up during COVID-19. System leaders want to ensure that the pressure to deal with the backlog of activity does not result in each organisation returning to a siloed approach and focusing only on their own individual priorities.

Enablers

The following factors were identified as playing a key role in facilitating effective system leadership during the COVID-19 pandemic, particularly in light of the need to act decisively and quickly:

  • Having invested a lot of time and effort into developing strong relationships with partners at the ICP and the ICS level prior to COVID-19 proved to be crucial when trying to respond effectively to the pandemic. The COVID-19 pandemic tested those relationships, but system leaders agreed that those relationships had not only survived but had strengthened under the pressure. Existing governance frameworks in place across each ICP and the ICS enabled partnerships to discuss relevant issues and make difficult collective decisions swiftly. They also allowed partnerships to ensure their COVID-19 plans were in alignment and complementary. Strong and trusting relationships also allowed for difficult decisions to be made quickly, often before guidance and directives had come from the centre. Furthermore, system leaders at ICP level came together to help collect, interpret and disseminate national guidance in a clear and systematic way.

The changes in the health and care act came in after the first of our patients began to move, so yes social care was directed to help, but our part of the system was already working up plans because we had trust and belief in what each other were saying so we knew we had to act now.

System leader from the Hertfordshire and West Essex Integrated Care System

  • Turnover of leaders within the Hertfordshire and West Sussex ICS is low and many system leaders have been in their role for over 10 years. Stable leadership has contributed towards the development of a partnership based on trust and transparency, which in turn has had an impact on the behaviours of system leaders during COVID-19. System leaders have not held back from offering unconditional mutual support.

Bit of a phenomenon in Hertfordshire… the chief executives and senior managers, we have all been around for quite a long time, more than 10 years. That is really unusual in systems. So we know each other very well… We all know everyone is doing their best and performing as well as they can… with leaders that are transparent and open, we fall over ourselves to help. Underlying everything is trust and transparency. If that breaks down then other behaviours breaks down.

System leader from the Hertfordshire and West Essex Integrated Care System

  • In particular, system leaders highlighted the importance of having longstanding positive and trusted relationships with county councils. It allowed systems to ‘go off script’ and make important collective decisions across health and social care, particularly when national guidance was only just emerging or not always helpful. Examples were given such as: creating a central system hub to collect and distribute PPE; redeploying staff to areas where they were really needed; and identifying empty wards that could be used as ‘quarantine’ areas for patients rather than discharging them straight into care homes. This was also supported by the fact that many social care colleagues were already successfully integrated into health organisations.
  • System leaders we spoke to reflected on the tendency for senior managers to deal with a crisis by trying to do other people’s jobs. However, system leaders across the Hertfordshire and West Sussex ICS were careful not to make this mistake and on the whole focused on supporting their colleagues to carry out their own jobs as effectively as possible. This was seen as a key factor in what worked well and facilitated effective system leadership.
  • Overall, system leaders said that across the system partners were more willing than ever to offer and provide help without expecting anything in return. Similarly, partners were finding it much easier to ask for help. Alongside this, the sharing of resources (such as staff and PPE) occurred freely and willingly, with no arduous negotiations required.

Behaviours and capabilities

Having explored in the main report how the core skills, capabilities and behaviours that system leaders now require are very different from what leadership roles demanded in the past, this case study probed into what behaviours and capabilities had emerged as most integral amongst system leaders when responding to the COVID-19 pandemic. A number of essential capabilities, skills and behaviours were identified by those we spoke to and are outlined below:

  • System leaders have had to support huge numbers of staff who have had to deal with stressful and sometimes traumatic experiences during this pandemic. This has further emphasised the need for system leaders to focus on how to support staff mental health and wellbeing and quickly develop new supportive initiatives. Senior leaders we spoke to reflected on how this new emphasis now takes centre stage amongst all the different ICP and ICS workstreams. Alongside this, leaders have had to recognise their own stress triggers and identify when they might need to take a break. This has required leaders to be empathetic, resilient, thoughtful and calm.

It has been important for leaders to understand what keeps them going, understand their triggers, how to recharge their own batteries, and recognise when you need a time out and a rest – and to know when to stand in for others.

System leader from the Hertfordshire and West Essex Integrated Care System

  • System leaderswe spoke to feel that COVID-19 has further emphasised the importance of collaborative leadership. Many of the decisions and actions taken required strong relationships built on trust, and open and transparent dialogue. System leaders have needed to facilitate conversations, encourage compromise, build bridges, and ensure that all the voices were being heard around the table.
  • System leaders have had to make decisions and plan for unfamiliar situations that most did not have any prior experience in. They had had to be willing to lead, make difficult decisions and try different approaches without necessarily knowing what the right thing to do would be. They have had to do all this in a context where they know they will be held accountable for every decision they have made. They have had to be honest about what they do not know, and constantly draw others into the conversation to pool expertise and knowledge. This necessitates a brave and humble approach to leadership.

Being able to voice uncertainty without fear of losing leadership credibility has been important [for system leaders]. Some find that hard, particularly those with a more authoritarian style. Their self-worth is tied up with having to know the right answer. But in reality for these situations, no one knows the answers but you have to give it a shot.

System leader from the Hertfordshire and West Essex Integrated Care System

  • COVID-19 has necessitated that system leaders, at many different levels, be more open minded and understanding of the pressures that colleagues and partner organisations might be facing. The pandemic has led to an increase in kindness and compassion amongst colleagues. This has made leaders more willing to listen to other people’s concerns and more likely to support the agendas of their colleagues across the system. Some of the system leaders we spoke to felt that those who were more naturally empathetic found leadership tasks during COVID-19 easier.

COVID allowed us to recognise and be open to all the pressures that everyone is under a little bit more… There was an increased level of kindness and support for each other as individuals and for their roles in their individual organisations. And that enabled people to think slightly differently – because if you are thinking positively about someone or concerned about them or you are trying to work with them to reduce their anxieties, you are more likely to listen to what their concerns are and more likely to recognise their massive pressures to deliver a service… and you are much more likely to support their agenda as well as your own agenda.

System leader from the Hertfordshire and West Essex Integrated Care System

  • System leaders noted that during the COVID-19 pandemic colleagues have appeared more comfortable and willing to challenge negative behaviours. The pandemic has contributed towards embedding a working culture that allows for transparent and open conversations that will now call out damaging leadership styles. System leaders said it was now easier to initiate those difficult conversations and to respectfully challenge colleagues about their behaviours and push them to work more collaboratively.

Positive impact

System leaders highlighted the positive impact that COVID-19 has had on the development of multi-professional, collaborative leadership models and the journey towards integrated care:

  • COVID-19 has accelerated the journey that systems were already on towards integrated care and collaborative leadership models. The pandemic strengthened and hastened the development of partnerships at ICP and ICS level. This has been due to the almost immediate and necessary increase in the sharing of plans, resources and staff. System leaders talked about how COVID-19 gave everyone a clear common purpose, as well as a common enemy, behind which they all rallied. Partnerships suddenly had very immediate and concrete priorities that they had to mobilise around and respond to. It enabled system leaders to collectively focus, in order to make decisions on a daily basis.
  • COVID-19 required partnerships to work in radically different ways, as well as make changes incredibly quickly. System leaders reflected on how the pandemic had shown partnerships that working differently and making changes quickly is in fact feasible. It forced partnerships to be brave and ‘get on with it’ because it was not possible to ‘procrastinate’ or ‘put things off’. System leaders said that the pandemic also evidenced that patients and staff can adapt to new ways of working.

’[COVID-19] has probably pushed us forward – because with this crisis it has become necessary to do something different to keep our patients safe.’

System leader from the Hertfordshire and West Essex Integrated Care System

  • System leaders spoke about the impact COVID-19 has had on the perceptions and use of technologies. For example, one hospital has drastically revised up their yearly targets for the percentage of outpatient remote consultations. COVID-19 had led to large investments in technology and an increase in time spent on training staff to use these technologies. It has also opened up the space to meaningfully discuss the roles of new technologies going forward. The pandemic has also led to increased levels of information sharing, with for example different parts of a system now having new access to different portals. System leaders hope that partners better understand the benefits of increased information sharing.
  • System leaders reflected on how COVID-19 has led to new partnerships being formed, particularly with the private/independent sector. It has also highlighted partners that are missing around the ICP and ICS table, such as elected councillors and community leaders. The pandemic has also brought partners who were previously in the background to the fore, and the hope is that going forward these partners will play a much bigger role in the journey towards integrated care. This includes housing, public health directors, and the voluntary and community sector. It has also strengthened the partnerships with district and county councils, particularly around discharging patients from hospitals and around joint commissioning. Regular meetings have been set up with country and district councils (due to the incident and control processes that are enacted in emergencies), and the decision has been made by the Hertfordshire and West Essex ICS to continue with these meetings even after the pandemic is over. The spaces will be adapted so that ongoing important issues can be discussed collaboratively.
  • A key priority during the pandemic was to create as much capacity in the system as possible, which led to health and social care sectors having to think about how they could work together in more streamlined ways, and how they could share resources, information and staff most effectively. The extra COVID-19 funding that the NHS received also gave health and social care partners an opportunity to focus on finding solutions that made the most clinical sense and were in the best interest of the populations they are there to serve. It took away a lot of the administrative and financial barriers that often stand in the way of collaborative working arrangements between health and social care. System leaders reflected on how conversations were less transactional, and felt more like collaboration than negotiation. Whilst they understand that financial pressures will not disappear, they are keen for partnerships not to ‘drift back to that more transactional arrangement, and to talk about risk and gain share in a different way.’ (System leader from the Hertfordshire and West Essex Integrated Care System).

[COVID-19] reduced all the traditional barriers that are in place across NHS and social care… Organisational financial positions and objectives all get in the way and you all end up trying to do the same thing but all in very slightly different ways. But COVID allowed us to say let’s forget about all those competing priorities, we absolutely have one fundamental single common purpose, and that really enabled everyone to work differently together.

System leader from the Hertfordshire and West Essex Integrated Care System

  • Overall, system leaders felt that COVID-19 has moved the system forward into an arena where more partners genuinely understand that the population is best served by all organisations working together, with a collaborative approach to commissioning and the development of policies and strategies. Interviewees also noted that system leaders were more confident and willing to pushback, in a sensible manner, against directives from statutory organisation boards that would oppose system-wide objectives. There is a greater sense of freedom amongst system leaders to support system priorities, even when it goes against organisational priorities.

The absolute key lesson [from COVID-19] for our system has been that recognition that we are all here to serve the population and although we happen to be employed by different organisations to do that, our service to them is fundamentally better if we link it up, as supposed to offering a fragmented piece-meal journey, where we allow the confines of organisational boundaries define the offer.

System leader from the Hertfordshire and West Essex Integrated Care System

Supporting and developing system leaders

We asked interviewees what areas they felt system leaders required better support and development in, particularly in light of COVID-19. System leaders agreed with the findings in the main report – about the need for a varied menu of support and leadership development programmes, as well as the need for development programmes to identify the next cohort of leaders, in order to prepare them to take the reins in the future. System leaders highlighted certain areas where they felt support and development for system leaders would be beneficial:

  • System leadership development would benefit from a focus on the importance of trying to understand the differing perspectives, objectives, experiences, and pressures that other leaders within the system might be facing. The ability to be able to stand in other people’s shoes was seen as an incredibly important element of any system leader’s tool kit. Development programmes that bring colleagues across organisational boundaries together, particularly from organisations in conflict with one another, to identify common objectives and understand the different contexts, were seen as crucial.
  • Leadership development programmes should focus on the importance of trust when building relationships. A deeper understanding amongst system leaders is required around the definition of trust and how one goes about building trust.

’I’m a big fan of trust and how important it is for any relationship… you get a lot of stuff done through trust. There is not enough focus on trust itself… We need to have more overt conversations as senior leaders across an ICS, where everyone has different priorities, about what trust is, how you build trust, and the importance of it… By focusing on the trust element it will create more open and honest dialogue which will ultimately drive the changes for the benefit of patients.’

System leader from the Hertfordshire and West Essex Integrated Care System

  • Leadership development programmes should upskill system leaders in how to prioritise, effectively define and clearly articulate system priorities. Furthermore, it is important for senior leaders to know how to encourage collective development and ownership of those priorities across the system partnership.
  • These case study interviews further emphasised the importance of a problem-solving approach to leadership development programmes that brings colleagues together from different sectors and organisations within the ICS or ICP in order to address a common issue. In fact, it was suggested that having leaders across a partnership come together to find solutions to common problems (such as COVID-19) would be a more effective learning process than formal development leadership courses. Having external facilitators support this process was seen as helpful, and one interviewee cited the external support provided by NHS England to help STPs become ICSs in the ‘accelerator areas’ as a prime example.
  • Leadership development programmes should focus on ensuring system leaders understand how to identify and support their own mental health needs as well as those of their colleagues.

Next steps

  • System leaders within their own organisations, as well as at ICS and ICP level, are beginning to take stock and reflect on the lessons learnt during COVID-19. It is important to think about how to capitalise on the positives and ensure they are embedded and maintained (such as the speed at which changes took place, the effective new ways of working, and the accelerated pace of collaborative working).

We have started to take the learning [from the COVID pandemic]… and we have a weekly senior management meeting now rather than a fortnightly one now that is looking at what have we learnt, what can we do differently, how can we maintain the energy and the drive, and the speed of change, and the support for each other and that level of kindness – into the future.

System leader from the Hertfordshire and West Essex Integrated Care System

  • System leaders see COVID-19 as an opportunity for the ICS and ICPs to review their priorities. Leaders felt that currently partnerships were trying to focus on too many priorities, and there was a need to hone in on the most important ones. Furthermore, this is a chance to clarify what each priority really means and to clearly articulate the objectives. This opportunity for reflection could also be a chance to be braver and more ambitious going forward.

We will look at all our programmes going forward – and say in light of COVID – is that programme fit for purpose, do we need to adapt it – or scrap it and start again. Perhaps with some areas we can be more ambitious.

System leader from the Hertfordshire and West Essex Integrated Care System

  • Concerns were noted about the implications of COVID-19 for the nationally-led direction of ICPs and ICS going forward. System leaders worried that the national focus would be o push for ICSs to become regulatory or statutory organisations, which in turn might side-line ICPs. The system leaders we spoke to from the Hertfordshire and West Essex ICS acknowledged that every system might be different – but that for them ICPs have been the integral vehicle for the transformational changes that has occurred. The role of the ICS is very much seen as a community of practice that is there to support ICPs. The hope is that there will not be a nationally-driven initiative that hinders the development of ICPs.
  • System leaders hoped that going forward, COVID-19 will lead to a greater focus on prevention and support for staff wellbeing. Furthermore, they mentioned the importance of creating development opportunities for many members of staff who have had to take on roles outside the scope of their current job remit during the COVID-19 pandemic. Many staff have proved themselves very capable of carrying out a range of different roles and should be given the opportunity to explore and develop in areas they have consequently found an interest and ability in.

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