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Report prepared for the NHS Leadership Academy
Future of care No 9 – November 2018
This Future of Care paper, aimed at chief executives, directors and senior managers from the NHS, local authorities, housing organisations and voluntary and community sector, is based on findings from interviews with systems leaders and a review of the literature. The NHS Leadership Academy commissioned SCIE to undertake this research to further expand the understanding of systems leadership and leadership of integrated care systems. The research will inform the Leadership Academy’s long-term plans for supporting leaders in integrated care systems. Quotes from these leaders are presented throughout the report.
the biggest national move to integrating care of any major western country.
Our health and care system is experiencing unprecedented pressures. The population is rising and ageing, and more people are living with complex and long-term conditions. Funding is hugely constrained and there are vacancies and skills gaps across the workforce. For decades, it has been widely agreed that breaking down organisational barriers through better integration has the potential to deliver higher quality care that achieves better outcomes and uses resources more efficiently. Yet this goal remains elusive in practice.
We need to learn to walk in each other’s shoes; building relationships through changes that need to be made.
David Pearson – Corporate Director, Adult Social Care, Health and Public Protection and Deputy Chief Executive at Nottinghamshire County Council
The drive towards integrated care gained new form and impetus with the publication of the NHS Five year forward view (NHS England, 2014), and Next steps on the NHS five year forward view (NHS England, 2017). These required NHS commissioners and providers to work together to develop sustainability and transformation partnerships (STPs) to improve services, taking a population-based approach to their geographical ‘footprints’.
Where such strategic partnerships and collaboration are most advanced, STPs have now developed further to create integrated care systems (ICSs) – where NHS commissioners, providers and local councils work collaboratively, taking collective responsibility for resources and population health.
ICSs have no statutory basis, but depend on voluntary collaboration between NHS and local authority leaders to develop a shared, system-wide approach to strategy, planning and commissioning, financial and performance management, and driving integration of care and services.
The first 10 ICSs started in 2017, and four more were announced in 2018. NHS England intends that other areas will become ICSs over time. Effective systems leadership will clearly be crucial to the success and impact of ICSs. Integrated systems require distinctive leadership skills and a unique strategic perspective that may differ significantly from traditional ways of leading health and care organisations.
This paper looks at the components of effective systems leadership in the context of ICSs and STPs. Drawing on an evidence review and interviews with ICS leaders, we explore how they are working in a system-wide way across organisational boundaries, and the leadership skills and qualities they require. The paper also looks at the challenges and barriers to effective systems leadership in ICSs, and what enables people to overcome them. Finally, it sets out ways in which the support and development needs of systems leaders can be addressed.
The 2014 NHS Five year forward view represented a major policy shift away from a competition-based model of health care, towards collaboration and integration. It recognised that organisations working together, sharing know-how and resources, were more likely to meet the significant challenges of rising demand, limited funding and the need to improve outcomes and patient experience. Simon Stevens, Chief Executive of NHS England in NHS moves to end ‘fractured’ care system (NHS England, 2017), recently called it the biggest national move to integrating care of any major western country
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The first 10 ICSs vary considerably in geography, demography, population size, drivers for change and number of partners involved. But they also have many characteristics in common:
ICSs are an example of integration at organisational, strategic and planning levels. They are intended to underpin, and result in, integrated care at service and patient levels. The governance and delivery structure can be complex, and is not underpinned by a statutory framework. Professor Chris Ham of The King’s Fund described the approach as follows:
It is important to recognise that ICSs have no basis in law and are entirely dependent on the willingness of the organisations involved to work together. NHS trusts and CCGs [clinical commissioning groups] have their own statutory duties and members of their boards may need reassurance that these duties are not being compromised by ICSs … Different accountabilities in the NHS and local government may also cause tension.
Professor Chris Ham, The King’s Fund. The journey to integrated care systems (NHS Providers, 2018)
ICSs are part of a larger drive towards collaboration and integration that affects the whole of the English NHS. At the very least, all NHS commissioners, providers and local authorities in England are now expected to be involved in STPs, which necessarily means working together and focusing on place and local population. Many are testing new models of care and some are developing integrated care partnerships (ICPs) – these adopt a looser approach to collaboration than ICSs, focusing on delivery without formalised collective responsibility and shared risk.
By their nature all these approaches are experimental, but expectations are high. NHS England hopes that the early ICSs will generate learning for the whole of the health and care system, while also producing meaningful benefits in terms of outcomes, patient experience and efficiencies.
ICSs are set to become a permanent feature of the health and social care landscape. Michael MacDonnell, National Director, Transforming Health Systems at NHS England, recently made it clear that collaboration and integration will remain central to the forthcoming 10-year NHS plan:
The long-term plan for the NHS, which will be published in the autumn, will set out how we intend to catalyse [ICSs] across the country, supercharging their spread. These systems are the opportunity and the vehicle for providers to be at the forefront of evolving a health service fit for the next 70 years.
Michael MacDonnell, NHS England. The journey to integrated care systems (NHS Providers, 2018)
The leadership model for health and care continues to shift from one that is hierarchical and focused on a single organisation, to one that involves leading change across a whole range of organisations using influence rather than management direction.
Leadership in ICSs is very much a form of systems leadership, but those in leadership roles told us they face a different and more complex set of challenges. It was described by one leader as ‘turbocharged’ systems leadership. The role of systems leaders is emergent and evolving, and the support they need is also likely to evolve further.
Leaders told us that they were expected to manage the following new demands.
There is an important role for us as senior leaders to build the vision and make the strategic connections. But, increasingly, systems leadership will operate within neighbourhood teams (MDTs).
Local government leader, ICS
The findings of this study are structured around the four domains of the NHS Leadership Academy’s Systems Leadership Development Framework:
The leaders of ICSs told us that they are increasingly expected to understand how to develop the right conditions locally to foster innovation. They are also expected to understand how to scale innovation (e.g. from a pilot or new model of care developed elsewhere, to other parts of the local system). This means that leaders must encourage colleagues to test new approaches and learn from innovations (e.g. in areas such as technology and self-care), and they must be ready to offer additional support to staff if and when an innovation does not succeed.
Leaders in ICSs told us that they need to have a strong focus on outcomes. They must be able to steer conversations and decisions away from organisational-specific objectives, towards broader outcomes for communities, such as reducing social isolation and promoting self-care. This is likely to mean that over time there will be less focus on traditional hospital-based metrics, and greater attention to the wider determinants of health, such as people feeling socially connected and able to support their own care.
I am thinking more and more about how we support thriving communities, building on people’s assets. Yes I have to track whether we are bringing down unnecessary referrals, but in the long run we need to be all focusing on these longer-term outcomes for communities.
Senior clinician, ICS
As well as workshops involving staff and the public, mechanisms for senior leaders from across the system to come together and have honest face-to-face discussions are crucial. Leaders told us that using skilled external facilitators had been vital in enabling them to build trust, bring tensions to the surface and discuss difficult issues. In this context, NHS Leadership Academy interventions around whole-group leadership development were welcome.
View: Enablers and barriers of innovation and improvement
Leaders of ICSs need to be able to build productive relationships. They told us that they spend more time than ever before developing good relationships with colleagues and, as part of this, trying to listen to and empathise with their concerns and issues. Often these relationships are fostered outside formal meetings, with lots of ‘pre-work’ on the phone or over coffee to prepare for more formal partnership meetings.
Leaders must also be able to establish governance structures which drive faster change, rather than being beholden to complex arrangements no longer fit for purpose. People spoke about the need to sometimes break up existing structures when they are not performing, and go where the energy is strongest or where there are governance structures that work well already.
To make change happen on this scale, leaders need to be increasingly effective at working collaboratively – not only with staff from across the system but also with patients, people who use services, elected politicians and citizens. Changes cannot be imposed but must be supported by the wider community. In Frimley Health and Care ICS, for instance, they have recruited and developed ‘community champions’ to reach out to communities, and in Surrey Heartlands they have established a resident panel to get involved in service co-design.
Leaders told us, however, that good stable leadership relationships take time to build. Some of the most successful ICSs have long-standing and trusting relationships across the senior level in the system.
Leaders spoke to us about how their roles were often highly challenging and isolating. Those new to a leadership role, in particular, need greater support and encouragement and a recognition that it takes time to develop the capabilities and behaviours required to lead challenging systems.
View: Enablers and barriers of relationships and connectivity
Leaders of systems are unlikely to succeed in such a complex and diffuse operating environment if they seek to control or direct change. Leadership in ICSs is more about setting an ambition and the direction of travel, the goals and the behaviours expected. The onus is on leaders to build a distributed leadership model, and foster a culture of leadership at all levels within the system.
ICS leaders are increasingly expected to support the development of MDTs, a process which is being accelerated under ICSs. In practice, this means you need to be good at building the right conditions in which MDTs can thrive (e.g. working with leaders from other agencies to remove barriers to data-sharing and budget-pooling, devolving more decision-making to MDT leaders and encouraging joint staff development).
Those we interviewed also talked about the importance of systems leaders having an entrepreneurial mindset, and being open to alternative ways of doing things. At times this means that leaders are expected to be disrupters, introducing different ideas and innovations into decision-making.
It’s challenging but also exciting: it puts you on a personal footing with the work that you do.
Christina Quinn, Director, South West Leadership Academy; Thames Valley and Wessex Leadership Academy; Kent, Surrey and Sussex Leadership Academy
In Buckinghamshire ICS, for example, there is a strategic commitment to access external support and rapid learning with other like-minded systems, maximising efficiencies of collaborating and enabling us to move at a faster pace through our organisational development programme.
Leaders told us that another core skill was translating complexity – such as a set of complex policies and initiatives – into something that is easy to communicate and use to build commitment for change.
This could include, for example, creating logic models or plans on a page to explain why change is needed and how different activities are intended to bring about that change. The SCIE Logic Model for integrated care, which we developed for the Department of Health and Social Care (DHSC), seeks to capture a complex system into a single page, as shown below.
Leaders told us that they needed to be increasingly skilled at designing and facilitating whole-systems events and workshops to build consensus and deliver change, and manage often difficult conversations through good listening and negotiation skills. Leaders told us that they needed to be very good at ‘deliberative’ engagement techniques, which involve providing people with information and time to consider options, before arriving at decisions.
Leaders recognise that huge cultural change is needed, given that until recently the NHS approach to improvement was based on competition between organisations, not collaboration. This shift can be harder for many middle managers and those in ‘back office’ positions than for people in patient-facing roles. And yet, unless staff at all levels really start to think and work differently, integrated care will not become embedded. Possessing a strong understanding of how to lead cultural change and a familiarity with the tools and techniques, such as coaching and action learning, may help make this happen.
In many ICSs, systems leaders are increasingly expected to build system-wide learning and evaluation frameworks which enable them to capture and act on the lessons from innovation. Pilot programmes are also commonplace in ICSs – it is important that arrangements are in place from the start to support formative learning. In Surrey Heartlands, for instance, which is developing a new single care record, an evaluation framework has been established which enables people to learn – in real time – from the implementation process.
Building a learning culture across the system is also important. This involves leaders bringing together and aligning skills development programmes (e.g. health and social care leadership), developing groups of champions who will disseminate learning and good practice, and finding ways for people to learn together more informally (e.g. through peer networks).
View: Enablers and barriers of learning and capacity-building
Key features of systems leadership identified by the literature.
This research has identified a number of factors which can facilitate or hinder effective systems leaders, across the four features of effective leadership discussed in the previous section.
A key theme from our research was the importance of working together to create a shared vision. Leaders told us about workshops involving people from many organisations and professional disciplines aimed at identifying priorities, outcomes and goals together, without a pre-set agenda. Such an approach builds relationships and trust, and enables people to better understand each other’s perspectives and identify what each can contribute. It helps generate a shared commitment to collaborative ways of working, and to the priorities and outcomes that are agreed as a result.
Although all ICSs are taking steps to involve local communities, patient representatives and the voluntary sector, there is a long way to go to ensure widespread co-production with patients and the public. For these approaches to become the norm, more must be done to develop professionals’ understanding of both the theory and practice of co-production, participatory approaches and community engagement.
Systems leaders are concerned about the fragility of a system that has no statutory basis – ICSs are dependent on the voluntary participation of all organisations involved, and a partner organisation could, in theory, walk away in response to an irreconcilable disagreement. However, many leaders suggested the multiple differing requirements made of partner organisations is a greater challenge on a day-to-day level. They cited a lack of alignment between national bodies, especially NHS England and NHS Improvement, resulting in inconsistencies in policy, priorities, expectations and requirements. Systems leaders want national bodies that are more enabling and permissive, less prescriptive and better coordinated with each other.
View: Features of effective systems leadership of innovation and improvement
The importance of honest and high-trust relationships was the strongest and most consistent theme from our research. Leaders stressed the investment of time and effort required to build trust and mutual understanding – there are no short cuts. Being able to appreciate issues from the perspective of people in other roles and organisations is key.
The involvement of local councillors was identified as highly important. There is a tendency for NHS senior staff to focus on relationships with local authority executives, but not always acknowledge the role of elected councillors. This requires careful relationship-building, as each ICS involves several local authorities of differing political complexions.
NHS board non-executives and elected councillors may not have experience of whole-systems and integrated working, and there is a need to invest in developing their understanding.
Leaders face particular challenges in striving for greater integration of strategy and operational plans across NHS and local authority organisations, with their differing cultures, expectations and regulatory requirements. There is pragmatism and understanding of these differences, but also frustration at the effects.
In system working, relationships are critical, they make or break success. As more ICSs develop, we have to get the message over that this took time. We have been working on productive relationships for well over three years. We have been building trust and supporting a new generation of leaders to come through locally. It takes time.
Chief executive of NHS organisation and leader in ICS
These barriers go beyond cultural differences and represent complex legal and technical dissimilarities in the requirements made of local authorities and NHS bodies – issues which cannot be resolved without national guidance, decisions or legislation. In the meantime, ICS systems leaders frequently need to resort to complicated ‘work-arounds’.
View: Features of effective systems leadership of relationships and connectivity
Unsurprisingly, individuals differed in the kinds of support and development they had found most useful. Many spoke favourably about structured leadership development programmes (some focused on systems leadership), and formal or informal networks and action learning sets providing peer support. Opportunities to learn from others who had been involved in systems leadership were greatly valued.
Many leaders told us that a one-on-one coach provided invaluable support and space for reflection. One had previously used her coach at times of change (e.g. a new job or major project) but with the ever-increasing complexity of her role, she now speaks to her coach regularly, and expects all her senior team to have a coach.
As well as formal development, leaders stressed that constantly engaging with others in all parts of the system was important for their effectiveness. Getting ‘out and about’ to see services at first hand, and talk with staff at all levels, across all parts of the system, is not merely a ‘nice to do’ but an essential.
Looking to the requirements of emerging and future systems leaders, there is a need for more ‘entry-level’ development for those who take on such roles. It is increasingly important for health and care professionals from different disciplines and backgrounds to undertake development together. The leaders we spoke to recognised that system leadership skills need to become much more widespread, going far beyond those in the most senior roles. The more that people at all levels are able to initiate, drive and champion transformative changes, the more likely those changes are to be successful.
View: Features of effective systems leadership of individual effectiveness
For system-wide and integrated ways of working to become the norm, it is important to invest in staff skills at all levels, not just the top echelon of leaders. A starting point is helping people see beyond loyalty to their own organisation, enabling them to understand in straightforward terms the ambitions of the whole system.
The valuable role of skilled independent facilitators was highlighted. As integrated approaches spread through health and care systems, it will be important for facilitators and organisational development (OD) practitioners to ensure their knowledge and skills keep pace. Many do not yet have experience of working collaboratively with multiple organisations to achieve change in support of a shared vision.
The people who struggle the most with this are the middle managers, especially those in traditional roles like contracting and assurance, who feel their job is either quite a combative role or about servicing demands, holding to account … anything that is helping those groups would be enormously beneficial. Otherwise, there will be a big swathe of people that you’re not touching.
Chief executive of NHS organisation and leader in ICS
Local leaders need time, space and a consistent national approach if they are to build capacity across their organisations and systems. Such large-scale changes take time and sustained effort, over many years. Some fear that, while NHS England has allowed the first ICSs some degree of flexibility in developing governance arrangements and structures, the ‘centre’ may soon want to impose specific structures and reduce local autonomy. Leaders urged NHS England and other national bodies to ‘be brave’ and resist the desire to centralise – it is only through allowing systems leadership to grow and local ownership of change to flourish that we, collectively, will be able to achieve transformation at the scale required.
View: Features of effective systems leadership of learning and capacity-building
The systems leader within an ICS faces a daunting range of challenges. Their role, as we described earlier, is evolving and emergent and their support needs will most likely change over time.
It is clear from this research that there are some areas where additional support would be welcomed. Leaders told us that their role was often isolated, and that while they could draw upon good managers to help them in most cases, additional help with facilitating complex change programmes would be invaluable. This could take the form of help to plan and deliver a large-scale event with the public, or help to facilitate a difficult conversation which may have become ‘stuck’.
Systems leaders told us that they can often feel quite isolated, and may not even have a team which reports to them. They welcomed having access to ‘safe spaces’ to share their views and concerns with others who have a similar role, either through informal networking or something more structured, such as a peer network. Help would be welcomed from organisations like the Leadership Academy, to match leaders to peers with similar backgrounds or interests. Several leaders told us that they welcomed having access to alumni who have rolled out leadership programmes they previously took part in, such as the NHS Leadership Academy Bevan Programme.
It’s important that you have self-belief that you’re doing the right thing.
Jackie Pederson – Chief Officer, Doncaster Clinical Commissioning Group
Leaders increasingly need to lead change with people from different professional disciplines and sectors. Leadership programmes that successfully brought leaders from different organisations together were welcome, because they helped to break down barriers and build mutual understanding. There was a desire for the Leadership Academy to do more to ensure that its programmes bring together leaders from across the whole system, including social care, housing and the voluntary sector.
Middle managers and people leading MDTs can often find it difficult to represent both the system and their own organisations and teams. Leadership programmes that help this group manage this tension and execute system-wide change would be welcome in many local areas.
Leaders often told us that while they usually had several specialist areas of knowledge, (e.g. social work or general practice), they were increasingly required to have a good understanding of an even broader range of topics. This knowledge was essential if you were to be successful in leading often difficult conversations with colleagues and professionals from across settings and specialisms with sufficient confidence and a sound grasp of the context and nuances.
Many of them would welcome opportunities to learn more about:
The NHS Leadership Academy seeks to equip leaders of integrated care systems, and other whole-systems approaches to integrated health and social care, with the skills and capabilities to transform health and care.
The outcomes being sought through this work include:
The NHS North West Leadership Academy (NHS NWLA) aimed to identify the kinds of behaviours that are needed to improve system leadership across the public sector in the north west. It looked to harness the wisdom of people working across the system to support population health.
Representatives from the NHS, local authorities, police, fire, higher education, third sector and beyond worked together to share experiences, learn from each other and identify the key behaviours needed for effective system leadership across the north west.
Thirteen key themes were identified as being especially pertinent to system leadership including ‘building trust’, ‘collaboration and co-creation’, ‘relationships’, ‘bravery’ and ‘doing things together’.
The NHS NWLA took the behavioural themes identified at the stakeholder event to a much wider group of participants using an online ‘crowdsourcing’ platform. They analysed and refined the ideas and explored them in more depth with senior system leaders.
The NHS NWLA is exploring how these findings can best inform and shape current and future development.
The NHS Leadership Academy offers a menu of support for ICS’ and STPs ranging from our award winning core programmes to a more localised menu of ‘in place’ interventions and funding.
For more information, please go to the NHS Leadership Academy website for our core programme offer and contact your local NHS Leadership Academy team to have a conversation about your needs and more localised support.
6 December 2018
A webinar from SCIE, the NHS Leadership Academy and NHS England looking at the SCIE report: Leadership in integrated care systems. The NHS Leadership Academy commissioned SCIE to undertake this research to further expand the understanding of systems leadership and leadership of integrated care systems.
The panel, chaired by SCIE’s director of business development and delivery, Ewan King, was made up of Christina Quinn and Alison Jennings from the NHS Leadership Academy. Pre-recorded contributions came from Roger Davidson, NHS England, and Larry Gardiner, a carer and user from Oxfordshire who sits on SCIE’s Co-production Network.
The Social Care Institute for Excellence (SCIE) improves the lives of people who use care services by sharing knowledge about what works. We are a leading improvement support agency and an independent charity working with adults’, families’ and children’s care and support services across the UK. We also work closely with related services such as health care and housing.
As part of Health Education England (HEE), the NHS Leadership Academy’s philosophy is simple – great leadership development improves leadership behaviours and skills. Better leadership leads to better patient care, experience and outcomes. Our purpose is to work with our partners to deliver excellent leadership across the NHS to have a direct impact on patient care. We offer a range of tools, models, programmes and expertise to support individuals, organisations and local partners to develop leaders, celebrating and sharing where outstanding leadership makes a real difference.
Visit: NHS Leadership Academy website.
The SCIE Future of care series aims to stimulate discussion amongst policy-makers and planners about the future of care and support, based on analysis of developing evidence and projections for the future. Thanks to the NHS Leadership Academy for its support in developing this paper.
