System leadership for integrated care

What is it and how does it work?

Without leadership that can inspire and facilitate social and health care providers and commissioners to work outside their professional and organisational interests, the challenges to achieving integrated care will not be overcome. Therefore, the attitudes, values and behaviours associated with systems leadership will be needed for the long-term.

Research in Practice 2020

Systems Leadership is about how you lead across boundaries. It describes the way people need to behave when they face large, complex, difficult and seemingly intractable problems; where they need to juggle multiple uncertainties; where no one person or organisation can find or organise the solution on their own; where everyone is grappling with how to make resources meet demand which is outstripping them; and where the way forward therefore lies in involving as many people’s energies, ideas, talents and expertise as possible.

Better Care Fund Support Team 2019

In the past, those with responsibility for senior leadership in health and social care were largely focussed on ensuring the success of their own organisations. This reflected the environment in which they were leading as policy frameworks, financial incentives, and performance measurements were primarily based on the success of their organisations and the quality of services which they provided. Similarly, professional leaders represented the interests of their discipline to ensure that the importance of its roles and the connected status was maintained.

Systems leadership is an approach in which those who are leaders look beyond the interests of their own organisations or profession to that of the local system and the communities it contains as a whole. It recognises that the major challenges faced by health and social care systems are not ones to which there are known answers, and successfully overcoming them will therefore require new ways of thinking and behaving. Systems leadership is required not only by those who are most senior but also those who are responsible for leading services, teams, and the professional practice of others. It also needs to provide opportunity for those within lived experience of health and social care, and local communities, to influence and lead integrated care.

  • 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.

Explore system leadership

How does systems leadership support integrated care?

Factors were stratified into six key categories: organisational culture, workforce management, interorganisational collaboration, leadership ability of staff, economic factors and political factors. Leadership was deemed to be the most influential factor due to its intrinsic and instrumental role in influencing the other key factors.

BMJ 2022

Fragmented care is due to services being rigidly organised on which organisations receive funding to deliver a particular treatment intervention or type of support, siloed recording systems not facilitating effective communication between agencies about someone’s situation and needs, and professionals not always understanding each other’s roles and knowing how to develop collaborative working relationships. Such processes and behaviours are extremely challenging to replace as they are deeply embedded in how people work and uncertainty about how more flexible and person-centred arrangements will work in practice and with the available resources.

Systems leadership facilitates the adoption of more integrated care through creating a shared vision with professionals, managers, and those with lived experience of health and social care, about what the overall purpose of the system is, and how it can add value to the lives of individuals, families, and local communities. It provides a safe space in which people at all levels of organisations can think and act differently to explore innovative ways of working together and deploying resources. Systems leadership does not avoid difficult issues and potential conflict but through keeping the interests of the communities which it serves at the heart of decisions, works towards common understanding and agreed ways forward in partnership.

What do leaders need to succeed?

Transformation programmes need a dedicated leader with grit, resilience and credibility.

NHS Confederation 2022

Leaders in the NHS spend much of their time looking up, at the expense of looking out to the communities they serve.

Ham 2022

Visible and resilient leaders who inspire a sense of purpose, who have the key facts, and a grip on the key information.

Better Care Fund Support Team 2019

Systems leadership is often tough as it involves wrestling with complexity and encouraging others to consider new ways of working which differ from established practices. Leaders therefore need support as individuals to strengthen their resiliency and reflective spaces in which they can consider their leadership and how to further improve. Development is best undertaken with colleagues who represent different parts of the system, including those with lived experience of health and social care. Mentoring, communities of practice, and action learning approaches can be helpful enablers of shared learning. As diversity of perspective is central to better systems leadership, it is vital that there is encouragement and opportunity for those from different professional and demographic backgrounds to access such development opportunities.

To provide a supportive environment, local systems should develop a joint governance arrangement in which local communities have an influence alongside services and professionals. This should provide support and constructive challenge to system leaders. Developing shared metrics which are based on the agreed vision will provide the benchmark by which local implementation and impact can be understood and move away from single agency performance systems. National bodies should be clear on what they expect from local system leaders in relation to outcomes and provide them with sufficient autonomy to innovate and use resources flexibly with their local partners.

What is the evidence for outcomes and impact?

Where we have seen that leaders in systems have an understanding and appreciation of each other’s roles and responsibilities, this has helped to build relationships and improve outcomes for people.

CQC 2018

Research into the leadership of integrated care teams and systems is limited, with ideas often reverting to existing framings of leadership, where teams and organisations are less complex. Research also often focuses on the importance of who the leader is rather than what they do.

International Journal of Integrated Care 2021

Leadership is a complex aspect of practice to study in relation to better outcomes as it is challenging to separate out its contribution in relation to other factors. That said, it is clear from numerous policy and evaluation reports that the presence of system leadership is reported as a key enabler of integrated care. Furthermore, the contrary is also reported on a regular basis, i.e. the lack of such leadership was seen to be a major barrier to better co-ordination and more person-centred care. Alongside the difficulties of attribution, it is also the case that research regarding systems leadership to date has often based within the context of a particular locality and more generalisable conclusions regarding the scale and nature of its distinct impact are therefore not yet possible.