System leadership for integrated care

What is it and how does it work?

System leadership is about building relationships and connectivity across organisations and sectors to drive the improvement, innovation and transformation of services.

Effective system leadership is:

  • shared, participatory, diffused and co-productive
  • relationship building, personal and person-centred
  • place-based and community-oriented
  • adaptive and solution-focused 
  • capable of surfacing conflicts and consensus seeking
  • primarily accountable to people and communities.
  • Video transcript Open

    In the context of integrated care, systems leadership is the practice of enabling all local partners to work towards the same goal of person-centred, coordinated care.

    It’s about:

    • Strengthening the relationships between local partners,
    • Enabling changes to how services are designed and delivered,
    • Connecting care professionals and organisations, and
    • Removing barriers to better joined up care.

    Systems leaders set the ambition and goals for local systems through a compelling vision and narrative of integrated care, establishing a culture of collaboration by working effectively in partnership.

    Systems leaders champion change initiatives that will improve the standards and outcomes of care, whilst working with service users, front-line professionals and communities to co-design and co-produce solutions for better heath and care.

    The skills and behaviours of successful systems leaders reflect a collaborative style of working that underpins integrated care.

    Leaders must be able to influence outside of their positions of authority and across the whole system, not just within their own institutions – using persuasion and negotiation skills to seek consensus.

    But equally, leaders need to operate in an environment where they are able to plan for the long term, and are given the time and space to innovate.

    Where there is tolerance for things not working, including learning to ‘fail well’.

    There has to be trust and delegation of autonomy from the centre, recognising that responsibility for making change happen cannot be held centrally.

    Relationships need to come before structures – ideally drawing on established working relationships built over the years.

    There has to be clarity about how governance and accountability work, and responsibilities of individual organisations

    And ideally, stability in leadership positions across organisations.

    Research evidence not just from the UK but from across the world has shown a positive relationship between strong collaborative leadership and the implementation of integrated care.

    Effective systems leadership is therefore a critical enabler for success.

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How does shared system leadership support integrated care?

Integrated care is delivered through an array of emerging collaborative arrangements and local partnerships, from the Integrated Care Pioneers and the New Care Models to the Sustainability and Transformation Partnerships, Integrated Care Systems, and devolved authorities. While there is variation in depth of integration, governance structure, footprint size and scope of activities, their success depends on a strong shared system leadership, to provide and nurture a compelling vison and narrative of integration, a strong collaborative culture, and a commitment to place-based, person-centred, coordinated care. 

Leading change across organisations and stakeholders, and championing the integration of health and social care but also public health, housing, children’s social care, mental health and the voluntary community sector may be effectively achieved through:

  • co-designing and co-producing solutions with those who receive health, care and support, and work effectively with elected politicians
  • place-shaping, understanding how strategic plans relate to very locally-based neighbourhood teams. Understanding how to commission and deliver population improved health is another important skill
  • leading large-scale change, improvement, innovation and transformation
  • tackling complex issues, including cross-system workforce planning; shifting care out of hospitals and into communities; and planning for the winter
  • building commitment and ensuring leadership is rooted deeper within organisations, engaging middle managers and leaders of multidisciplinary teams in their thinking.

What do leaders need to succeed?

To effectively respond to the complexities of leading integrated systems and influencing and championing large-scale transformation, system leaders need to operate in an enabling environment where:

  • they are able to plan for the long term, and are given the time and space to innovate
  • there is tolerance for things not working, including learning to ‘fail well’
  • there is trust and delegation of autonomy from the centre – a permissive, not prescriptive, approach and national guidance that provides a broad, enabling framework
  • decision-making roles are distributed, and staff and service users involved; recognising that responsibility for making change happen cannot be held centrally
  • relationships come before structures – ideally drawing on established working relationships built over the years
  • there is clarity about how governance and accountability work, and responsibilities of individual organisations
  • there is stability in senior leadership positions across organisations.

At a professional level, leaders must be able to rely on:

  • communities of practice, ‘safe spaces’ where to share views and concerns and formal and informal networks
  • peer support and buddying up
  • leadership programmes, including using learning together approaches, bringing together professionals from different disciplines and sectors
  • Support for middle managers and distributed leadership.

What is the evidence for outcomes and impact?

Findings of a realist review of the evidence show that contextual factors such as strong and supportive leadership and joint governance are critical to the successful implementation of integrated care programmes, and to fostering a culture of collaboration (Kirst M. & al., 2017). Evaluations of integrated care programmes similarly suggest that:

  • ‘Strong, collective leadership is the single most important enabler for success in providing high-quality health and social care for people’ (Care Quality Commission, 2018)
  • ‘Strong leadership across the area’s organisations is essential to maintain focus and mitigate against the risk of change in leadership and loss of momentum’ (LGA, 2016)
  • Good leadership and project management are key in coordinating planning, and mobilising and sustaining support and engagement for BCF programmes at both strategic and operational level (Forder Julian et al., 2018).