This research offers timely and unique perspectives on leadership of integrated care teams and systems, in particular what works, for whom and in what circumstances. Its strengths are the careful analysis and unpacking of the assumptions of what leadership is amid the challenges of large, complex, inter-sector systems. The aims of this chapter are to set out the key messages from the study, review the approach and methods used, and discuss the implications of the findings for policy, practice and research.
Key messages
Paucity of empirical evidence
There was little evidence that specifically addressed leadership of integrated care teams and systems despite the widespread policy rhetoric in support of, and partial implementation of, this model of organising services. This was surprising. We assessed many papers and information sources, but most referred to older leadership theory, which was not tailored to understanding how leaders contributed to complex multisector organisations. There are several potential reasons for this. These include:
- Attention on and development of integrated care teams and systems is relatively recent, with the result that little research has been undertaken or completed.
- Research on integrated care teams and systems has focused on the implementation and outcome of service innovation rather than some of its structural underpinnings.
- The lack of literature could reflect how hard it is to research this area and a reliance on existing framings of leadership when teams and organisations are less complex.
- There are assumptions about leadership being a homogeneous activity that is transferable across many different settings and types of service and, therefore, it is not a research priority.
It is also important to note that there was very little evidence of the contexts that influenced how leaders work and even less evidence on the outcomes. Identifying CMO configurations was challenging. This limited the degree to which we could draw definitive conclusions about what works, for whom and in what circumstances. However, making explicit some of the assumptions about how leaders lead integrated care teams and systems has provided new perspectives offering fresh theoretical grounding that can be built on, developed and tested further.
There is an emphasis on the individual/personal qualities of the leader
The strongest evidence found in the review was around how leaders inspire people’s intent to work together in integrated care. This evidence focused on who the leader is rather than what the leader does. It referred to their personality, characteristics and ability to inspire other people. This is quite challenging to consider within aspirations for greater diversity and inclusion. One of our expert stakeholders asked: ‘If we just rely on people blowing us away with their personalities because they’re born like that, is that what it is?’. This seems counterintuitive. Why have extensive leadership programmes to develop, prepare and support leaders if the main qualities they need to lead well are innate? The stakeholders were clear that this was not enough; a leader must be knowledgeable, skilled and spend time on finding out what is involved on the ground. Within the ‘creating the conditions’ mechanism the focus was on the practical attributes of leadership, but stakeholders felt that it ignored the social skills also required. For example, stakeholders believed that ‘creating the conditions’ also involved creating a culture of psychological safety and an environment of transparency, openness and freedom to communicate without fear of repercussions.
The stakeholders referred to aviation safety, stating, ‘you don’t really care who the pilot is and how inspirational the pilot is when you get on the aeroplane, you just want them to fly the plane safely’. This overemphasis on the influence of individuals is recognised in leadership theory. The culture of individual leaders as ‘heroes’, romanticising their individual abilities and dispositions, is thought to prioritise the importance of being in control and having the power to decide, steer and influence others. This overestimates their contribution and influence598,599 and can obscure, in part, the tensions and complexities inherent in leadership.600
An alternative perspective is processual leadership,601 which views leadership as an ongoing process of social interaction and negotiation with all members and stakeholders of an organisation who participate in and influence the organisation’s activity. Processual leadership acknowledges the complexities of social reality. It focuses on how leadership is socially constructed, deconstructed, and reconstructed in a fluid and dynamic way as relationships and circumstances change.602 Through these ongoing processes, power and agency are negotiated between all actors in the organisation (e.g. leaders, staff and patients/service users) and no one falls outside these complex organisational processes.599 This is attuned to the stakeholders’ views of the importance of social skills and emotional intelligence. Developing processual leadership practices that are attuned to a complex, changing, organisational context is thought to require recognition of the value of disagreement, tensions and dissent. This is not to decry consensus but acknowledges that it is not always achievable where stakeholders inevitably have different views and professional values. Leadership in organisations that are characterised by complexity and ambiguity like integrated care systems require a ‘viable sense of self-as-a-leader’ where leaders accept that social reality is constantly changing, and that control is an illusion.599 However, maintaining a processual approach of leadership in an organisation or system where the dominant conception of the ‘hero’ leader is deeply embedded and where leaders perceive high levels of ambiguity and insecurity is extremely difficult.599 The theory of ontological security595,596 provides a useful perspective to our understanding that leaders need to feel comfortable and secure in a climate of uncertainty to provide this security to the systems and team members that they lead.
We propose that perpetuating the importance of individual characteristics of leaders reduces the scope for integrated care teams and systems to develop leadership practices that are attuned to the complexity of multi-sectoral, multiorganisational and multiprofessional working. Furthermore, in line with The NHS Long Term Plan,8 42 integrated care systems have been created to cover the whole of England from April 2021, growing out of Sustainability and Transformation Partnerships. It is intended that they will become commissioning bodies that have a partnership governance structure and performance framework and need to be held accountable, committing the NHS and partners to increased complexity of health and social care services. There is a timely need to ensure that the skills of integrated care teams and systems leaders are intentionally developed to keep pace with service reorganisations.
Absence of evidence of patient/service user perspective
A central policy driver for the introduction of ICSs was the need for services to be ‘integrated around the patient’,7 to provide the best patient/service user experience and the best value for money. The ambition was to support patients/service users to be actively involved in their own care, give them more power to manage their own health and make informed decisions about their care and treatment. Furthermore, NHS England’s Patient and Public Participation Policy603 states that:
One of the great strengths of this country is that we have an NHS that – at its best – is ‘of the people, by the people and for the people’.
It also adds that:
. . . we need to engage with communities and citizens in new ways, involving them directly in decisions about the future of health and care services.
It is a stark finding that we found no evidence of the patient/service user’s perspective of leadership or their involvement in leadership of integrated care teams and systems.
The importance of power
This synthesis found the exercise of the power and influence of leaders to be very important. Power was held by many people to varying degrees, by government, across sectors, in organisations and by individuals at all levels of activity. As discussed previously, there was no evidence of power and influence being held by patients/service users in this context. Historic imbalances of power between health and social care were clear and irrefutably demonstrated by the response to managing surge capacity during the first wave of the COVID-19 pandemic. The NHS Long Term Plan,8 which sets out plans for the integration of health and social care throughout England is NHS-centric and potentially reinforces significant existing tensions between health and social care. New legislation to create a ‘legal form’ for integrated care systems is expected in 2021.604 The NHS Long Term Plan8 did not call for new statutory bodies, but we believe that it will be important to provide clear power-sharing requirements to protect social care from being disadvantaged. This synthesis also demonstrated that higher levels of influence and power were held by members of the medical profession. Honesty and reciprocal trust were important in how power was used, which links to the individual characteristics of the leader and being known by those being led. The nature of power is far more complex and nuanced than the evidence suggests, and questions remain about how leaders of integrated care teams and systems see their power and reason how to use it. With the large size of integrated care systems and the numerous members of staff potentially involved, how realistic is it that leaders will be known sufficiently to be credible and trusted and to know the nature of the services that they are leading to make decisions?
The benefits of and barriers to pre-existing networks
The importance of system leaders looking beyond the interests of their own organisations and the integrated system to focus on the needs of the community was discussed in the research evidence. However, to facilitate this, leaders drew upon their pre-existing networks of like-minded people and those considered to be the ‘right people’ to engage with strategically. This would appear to be in contradiction to taking a wider view of the system. The benefits of pre-existing networks include that leaders are known and trusted, and progress in advancing innovation is likely to be faster, which is important given the political investment in the success of ICSs. It may also help leaders experiencing anxiety or uncertainty about the challenge of leading large, complex systems. However, a tendency to drift towards organisational, cultural and professional familiarities is likely to narrow the focus of innovation and this may inadvertently be a barrier to diversity in leadership. This lack of diversity could include sector, professional group, leadership style, service delivery priorities and protected characteristics, such as age, disability, ethnicity and sex. This reduction in diversity could reduce the potential for innovation, reach and equality of opportunity as demonstrated in the ‘Snowy White Peaks’ of the NHS report605 and hinder the ambition to ‘understand, encourage and celebrate diversity in all its forms’.606 If leaders have a background in one organisation (e.g. as a senior leader in the NHS), they will be aware of the needs of that organisation and address them more easily. Furthermore, will integrated care disadvantage the perspective or involvement of smaller, less resourced, less experienced sectors who produce fewer senior systems leaders, such as charities?
Lack of practical guidance about how to lead in integrated care teams and systems
Throughout the evidence, there were general statements about the important activities that leaders undertook in leading integrated care teams and systems. For example, they managed conflict and mitigated tension among team members, they looked beyond the interests of their own individual organisations and they encouraged team members to develop and innovate. However, there was very little explanation about how leaders undertook these activities, their reasoning for what the best approach would be, the trade-offs they may have made, and the challenges that they encountered. This limits our understanding of what aspects of leadership work, for whom and in what circumstances. In the same way that clarifying complexity was thought by our stakeholders to be an important responsibility of leaders (albeit with little empirical evidence), leaders also required clear directives at a strategic level from all agencies involved, as well as from government, about leading challenging processes. However, policy documents were thought to do little to address the day-to-day complexities of working in an integrated system and our stakeholders felt that there was no blueprint for leadership in integrated care.
Strengths and limitations
A key strength of the study was the use of a realist review approach. This made explicit the assumptions of how leaders lead integrated care teams and systems and has begun to unpack the inherent complexity in these structures and activities, thereby advancing knowledge. Although the paucity of relevant empirical literature is a significant weakness of the review and limits the degree to which we can draw definitive conclusions about what works, for whom and in what circumstances, the review has highlighted important gaps in what is known and has provided new perspectives, which give much needed theoretical grounding that can be built on, developed and tested further. Establishing the evidence as we know it now in a rigorous and insightful way provides a valuable springboard for future work. Our realist descriptions of programme mechanisms are long and detailed. This is a strength as they provide a rich description of leadership, but they were challenging to test in the literature. Another key strength was the intensive contribution of the study stakeholder group, who challenged the assumptions made in the empirical literature, contributed their extensive experience and expertise to add explanation to the empirical evidence and provided additional insights not addressed in the published literature.
During the review it was challenging to define an integrated team and integrated system. Existing definitions described what they did rather than what they were. This was somewhat surprising and required the team to write study-specific definitions. Furthermore, these terms were used in the empirical literature to describe a range of organisational arrangements and were often not aligned to the purpose of our review. Similarly, the terms ‘leader’ and ‘manager’ were used interchangeably. Our search strategy did not include the term ‘manager’ or a variant of this and so when retrieved papers used the term ‘manager’ rather than ‘leader’, we examined it to assess whether or not the activities reported were those expected of a leader. Finally, the study team worked hard to overcome the challenges of COVID-19, which imposed remote working on the final 6 months of the study. It has been difficult to have detailed, theory-developing discussions between the study team and the expert stakeholder group via teleconferencing platforms and this has inevitably curtailed the intensity of these discussions. However, we completed the review under these circumstances.
Implications for policy and practice
This review demonstrated the weakness of the evidence explaining how leadership of integrated care teams and systems work, the contexts that support these mechanisms and the resulting outcomes. However, it revealed the scope for considerable variation in leadership practices. The prominence of the policy imperative to expand implementation of integrated care systems throughout England, and the importance of leadership to achieve this, highlights the contribution of this review. The fifth study objective was to provide recommendations about optimal organisational and interorganisational structures and processes that support effective leadership of the integrated health and social care system. However, making recommendations would overstate the evidence available. Therefore, the implications for policy and practice are set out in the following sections.
Implications for governance structures
New legislation in 2022 to create a ‘legal form’ of ICSs is expected at the time of writing.604 The findings of this review suggest that it would be very important to ensure that legislation provides clear power-sharing requirements to protect social care and non-NHS organisations from being disadvantaged. Clarifying complexity and designing governance and incentives structures to support ICSs, rather than individual organisations within the systems, is likely to support leaders to take a wider view. This study will inform leadership structures for these new governance structures.
Implications for education preparation of leaders of integrated care teams and systems
The review did not find much evidence on specific education preparation for leaders of integrated care teams and systems. However, some important considerations were highlighted. These include:
- the importance of understanding the whole system, which suggests that leaders need a wider understanding of organisations
- the highly complex, dynamic nature of leading integrated care teams and systems and the imperative to adapt to varied circumstances demonstrates that leaders need to develop a viable sense of self-as-a-leader and be comfortable with uncertainty and ambiguity rather than the command and control approach that is common in the NHS
- acknowledgement of the importance of emotional intelligence, communication and social skills development in leadership preparation.
In view of the unique, highly situated context of leading integrated care teams and systems, we propose that leadership training needs to encompass not a generalised training programme or course, but instead bespoke, individualised mentoring/coaching programmes. Approaches that increase exposure and understanding of other sectors may be useful, such as work placements, coaching or secondments, where individuals have opportunities to shadow leaders from another part of the system, work with coaches from other sectors, or rotate between the range of organisations across the system. Innovation approaches to design leadership education and training to build networks across systems would be beneficial and would contribute to the plans outlined in the NHS People Plan.606
Implications for individual leaders and integrated care teams and systems
This review carefully unpacked the available evidence on the assumptions of what leadership is and the unique challenges of leading large, complex, inter-sector systems. To our knowledge, this is the first realist review in this area and offers leaders insights about their actions that potentially affect care delivery and outcomes, and team and system working. We hope that this understanding supports leaders to reflect on their practice and the factors that may support them in their work.
Recommendations for further research
The paucity of empirical evidence included in this review demonstrates the need for further research in this area, particularly as ICSs are being implemented throughout England. Furthermore, with the increasing range of structures for integration there is an increasing need to understand what works within a number of different closely specified system conditions (e.g. horizontal/vertical leadership and type of governance agreement/contract). The refined programme theories provide a very useful conceptual framework or platform from which to build this evidence.
This study has identified that research is needed in the following areas:
- A clear priority is the need to examine patients’/service users’ and carers’ perceptions of how ICSs support them to have the opportunities to be involved in and lead their care.
- Testing and evaluating these realist theories through research using a range of designs including in-depth case studies, ethnographic exploration and longitudinal research would provide a targeted explanation of how leadership works, the contexts that influence these mechanisms and the resulting patterns of outcomes.
- In initial theory development we identified political astuteness as being necessary for leading integrated care teams and systems, but we found no mention of it in the research evidence. The expert stakeholders advised that leaders cannot operate without a sense of political leadership and therefore this area warrants research.
- Understanding the reasons why the individual characteristics of leaders and ‘hero leadership’ are so prominent and how leaders can be supported to be able to take a processual approach to leading that is more comfortable with complexity and uncertainty in the system.
- Investigating the notion of ‘fostering resilience’ in leaders, what this means and how it develops. Although there was no research evidence about this, our expert stakeholders were concerned that this may mask anxiety and avoid adequate management; they suggested that it would be useful to explore the cultures that leaders set around this. Furthermore, increasing understanding of the impact of self-care initiatives to develop leadership resilience would be useful.
NHS England and NHS Improvement set up the NHS leadership observatory in 2021,606 which aims to commission research and translate findings into practical advice and support. This review has the potential to inform the research priorities for this observatory.
Final conclusions
To our knowledge, this is the first theory-informed realist review of leadership of integrated care teams and systems. It makes a significant contribution to the understanding of what is known and, perhaps more importantly, the gaps in the empirical evidence. The emphasis on the importance of the individual personal characteristics of leaders, supporting the image of the ‘hero’ leader, suggests that there is discomfort and a lack of security in dealing with the high level of complexity within integrated care systems. Imbalance of power between sectors, organisations, teams and professionals is demotivating and a barrier to integrated working. The NHS is considerably more powerful than other sectors, emphatically demonstrated during the COVID-19 pandemic, which needs to be carefully considered if legislation formalises the structure and governance of ICSs in 2022.