Discussion

This chapter reports how understanding of the programme theories or mechanisms has been refined following the synthesis of empirical research and stakeholder consultation. A key task in this synthesis was to make theories around leadership of integrated care teams and systems explicit, by developing clear hypotheses about how and for whom their leadership might ‘work’ and why. Sources of data used to develop the initial programme theories included academic peer-reviewed papers, policy documents and grey literature, which were discussed at length and modified by key stakeholders. These initial programme theories were then tested using research evidence and the experience of stakeholders to examine if leadership works in the way it was expected or assumed to work. This chapter presents the degree to which the initial programme theories were supported by these sources of evidence.

Inspiring intent to work together

The ‘inspiring intent to work together’ mechanism was the mechanism most often identified in the synthesis and the mechanism that generated the greatest amount of detail and discussion in the research evidence and among stakeholders. This mechanism was unique in that all others discussed what the leader does, whereas this discussed who the leader was. It referred to the personality and characteristics of the leader and how they were able to inspire other people.

There was evidence to support most of the initial programme theory (e.g. evidence that leaders were required to be effective advocates for integrated care, including having a clear vision for integrated working, which they could articulate with dynamism, passion and enthusiasm), but this was not all. That is, the initial programme theory stated that integrated working was based on voluntary collaboration without statutory basis, yet research evidence pointed to formalised integration either through the merger of existing hospitals/departments or through the development of NHS and Social Care Trusts. Furthermore, both research evidence and stakeholders’ experience indicated that inspirational leadership alone was inadequate within integrated care and needed to be supplemented by a range of other attributes. Stakeholders talked of the need for credibility, authenticity, and emotional intelligence, whereas the research literature identified the need for good communication skills; an open and accessible profile; and the ability to deliver a clear, consistent message. Stakeholders also noted the importance of leaders basing their vision around the needs of their patients/service users – a notion not given prominence in the research literature. There was also evidence of the absence of this mechanism in integrated teams and systems, both from the perspectives of stakeholders and the research literature. The consensus was that inspiration was broadly inadequate when leading complex integrated teams and systems, whereas the research literature highlighted examples of leaders who lacked inspirational qualities. This led to leaders refusing to confront problematic team members or challenge difficult behaviours.

A facilitating context for this mechanism, not identified in the initial programme theory but supported by both the research evidence and key stakeholders, was the importance of the overriding presence of trust. This included both strategic trust (i.e. trust that systems leaders would ensure that the correct organisational processes were in place and the right strategic decisions would be made) and personal trust (i.e. staff’s trust in their team leader’s skills and priorities, as well as the trust leaders had in themselves and their own personal capabilities). Developing this trust took time, with one example in the research literature demonstrating that a decade of development was required. When trust had been established, staff demonstrated a willingness to participate in integrated working, even when this was not specifically required of them. The research literature also provided evidence that integrated working was hampered by recalcitrant team members, who slowed progress by working in silos owing to a lack of trust.

Inspirational leadership is a complex issue because, as key stakeholders confirmed, employees may follow a leader because of their place in the organisation’s hierarchy, not necessarily because they are inspirational or able to motivate their staff to deliver their best work or contribution. This poses the question: what does it mean to be ‘inspirational’? In this synthesis, several characteristics associated with being inspirational were identified, including being:

• visible
• credible
• committed
• enthusiastic
• dynamic
• confident
• willing to act
• able to motivate, empower and encourage others
• able to gain the trust and respect of others
• a good communicator and listener
• able to develop strong interpersonal relationships with colleagues
• able to foster professional altruism
• willing to ask for help.

This long list of characteristics highlights how the word ‘inspirational’ is a ‘catch-all’ term, which is arguably overworked, inflated and subjective. It raises several areas for consideration. First, it poses the question of whether or not organisations are likely to find an individual who possesses all the above characteristics. Take, for example, the requirement of ‘credibility’, which was reported to be gained through having direct experience of working in both health and social care or through being associated with previously successful developments. Given the relatively new status of integrated health and social care systems, the likelihood of finding an individual who has direct experience of working in both health and social care settings or having previously led successfully integrated teams or systems would be low. Every leader must become a leader for the first time and will, therefore, require the time and opportunities to hone many of the skills and experiences they may be expected to already possess. This suggests that more needs to be done to generate a pool of people with such credibility, for example by including training in both health and social care sectors as part of informal development opportunities as well as providing more formal leadership programmes, recognising that leadership development is both ongoing and progressive. The other reported means of demonstrating one’s credibility was through a leader’s ‘personality’, but there was no explanation of which personality traits helped to determine credibility. Taking the list of characteristics presented above, it could be assumed that credibility may be achieved through the demonstration of personality traits such as confidence, charisma, visibility, dynamism and influence. If so, credibility may be associated with personality traits of dominance and sociability, which have been identified as core components of the extroverted personality.589 One concern, therefore, is that appointments for leadership of integrated care teams and systems may be biased towards those with extroverted personalities, yet more research is required to determine if such individuals are better equipped to undertake these roles successfully. A second point of consideration is whether or not leaders of integrated care teams and systems would require all the above characteristics or if some inspiring attributes are more important than others. Key stakeholders reinforced the view that one person’s perception of what is inspiring will be different from another’s and that inspirational leaders will therefore be incredibly diverse. Rather than search for a universal archetype of an inspirational leader, it is suggested that integrated systems assess the leadership traits required in their own specific organisation to motivate their staff to deliver their greatest contribution.

Aside from the specific personality traits or attributes of leaders, this synthesis found that a key component of inspiring others was having a clear vision for integration, which was articulated to others with passion. The importance of ‘vision’ is not a new concept in either the general leadership literature or health-care leadership literature.590–592 However, while many authors talk of the importance of developing a clear vision, few clearly discussed what this entailed or how this could be achieved. Stakeholders also raised the importance of basing a vision around the needs of the individual patient/service user – a notion lacking prominence in the literature. Given the relatively new status of integrated care teams and systems, cultivating a strong vision for integrated working may be a skill that many leaders have yet to develop, and there are few ‘road maps’ available to assist with this. Furthermore, the research literature also identified the problems that could arise when the vision of team leaders did not align with the vision of their system leaders or the visions of the component organisations within the system. Given the complexities of ICSs, it is likely that varying organisations and leaders will have different visions of integrated working and how this can be best achieved. As this has been identified as a key component of leading integrated teams, it is suggested that effort is placed into developing a clear vision for integrated working that is accepted by all organisations and leaders in it.

Creating the conditions to work together

The ‘creating the conditions to work together’ mechanism was discussed as frequently as ‘inspiring intent to work together’ but lacked depth and detail. There was a clear overlap between these mechanisms regarding the importance of a leader’s ‘vision’. ‘Inspiring intent to work together’ referred to the need for leaders to have a clear vision for integrated working, which they could articulate clearly to others in an inspirational way, whereas ‘creating the conditions to work together’ involved leaders ensuring that the appropriate systems were in place to enable this vision to be achieved. Bluntly, leaders needed both a vision for integrated working that they could ‘sell’ to others in an inspirational way and have the skills to make that vision a reality. Although these mechanisms are separated here for the purposes of clarity, in reality, there must not be a disconnect between these two mechanisms, as both are important components for leadership. This notion was reinforced by the study stakeholders, who indicated that inspirational leadership alone was inadequate and needed to be supplemented by a range of other attributes.

Once again, the research evidence expanded on the initial programme theory by providing details of the practical steps that leaders needed to undertake to help achieve their vision. This included setting and driving an agreed strategy; creating a framework for action; re-drafting job descriptions to help facilitate collaborative working; ensuring effective organisational systems and processes were in place; and creating mutually beneficial shared goals with accountability for outcomes. Stakeholders further enhanced the programme theory by also highlighting the social skills required by leaders to create important conditions of psychological safety and an environment of transparency, openness and freedom to communicate. Also supported by empirical evidence and stakeholder contributions was the requirement for leaders to share components of their role with other members of their team. This idea of leadership sharing was based around the belief that integrated care required different skills at different times, not necessarily embodied by one person. Examples of shared leadership included delegating tasks and responsibilities. An important context for this mechanism was, again, whether or not there was an overriding presence of trust within teams, as the mechanism was facilitated in supportive atmospheres of professional respect and trust. Again, developing this trust took time.

Although ‘inspiring intent to work together’ and ‘creating the conditions to work together’ both centre around the importance of a clear vision for integrated working, the mechanisms describe different ways of enabling this vision to be achieved. The former focuses on the importance of leaders inspiring others to want to work together through their credibility and personality traits, whereas the latter requires leaders to have the practical and emotional intelligence and social skills necessary to achieve this vision. Although a similar number of papers discussed both mechanisms, it was notable that ‘inspiring intent to work together’ was discussed in far greater depth and detail than ‘creating the conditions to work together’. It is not clear why this may be the case. Perhaps the ability to inspire others is the most commonly accepted, attractive or valued component of leadership, whereas the ability to ensure that systems and procedures are in place is devalued or perceived as suitable for delegation to others. Perhaps these tasks and responsibilities are seen as the hallmark of managers and not leaders. Although we recognise that there is overlap and an interdependence between some aspects of management and leadership, it was not possible within the scope of this review to explore management in depth. However, the fact that both mechanisms were identified frequently suggests that both are important components of leading integrated teams and that investment in detail is as important as investment in vision. In complicated systems of integrated care, inspiration alone is not enough for the delivery of successful outcomes. Leaders who focus on inspiration alone may develop staff who are motivated to work in an integrated way but if the processes and procedures to enable such working are not in place, then positive outcomes will not emerge. Instead, effective leaders need to inspire staff to engage in a shared vision of integrated working, ensure that systems are in place to enable this vision to be achieved and hold staff accountable for their results.

Related to this was the suggestion by one author that developing a shared ‘team culture’ was an important factor in leading integrated care teams.92 In the same way that developing a shared vision may be complicated in integrated care teams and systems, developing a shared team culture may also be difficult and potentially unlikely. Health and social care organisations operate under different cultures, governance procedures, accountability, regulation, and funding streams and they work with different trajectories and metrics of success. Different philosophies of care also operate both within health-care systems (e.g. between acute care and rehabilitation) and between health and social care organisations. The notion of a shared ‘team culture’ in integrated care teams may not recognise the importance of professional cultures nor what may be important to patients/service users at different points in their trajectories. More discussion of the need to balance different organisational cultures is provided in the ‘balancing multiple perspectives’ mechanism.

Finally, another theme identified in the research literature and by stakeholders across both the ‘inspiring’ and ‘creating the conditions’ mechanisms was the need for shared leadership roles (i.e. the need for team ‘champions’ who reminded members of the team’s benefits and provided sustained motivation for integrated working). Project co-ordinators, who were specifically focused on the process of improving integration, were also recommended. This suggestion that the different skills required from integrated care leadership does not need to be (or is unable to be) embodied by one person arose more strongly in the research evidence than in the initial programme theory, suggesting that the practical experiences of delivering integrated care are more complex than perceived. Given the complexities of integrated working and the multiple perspectives required to deliver integrated care, these systems may be better suited to leadership structures that are shared rather than concentrated in a single leader. More discussion of the need for sharing leadership and the benefits and complications this may pose is provided in the ‘working with power’ mechanism.

Balancing multiple perspectives

Over half of the research papers included in this synthesis referred to the ‘balancing multiple perspectives’ mechanism, yet evidence remained limited for much of the initial programme theory. Only one paper referred directly to the historical power imbalance between health and social care and the negative impact that this had on integrated care, whereas others discussed the imbalance between different professional disciplines, with medicine typically having the greatest power and influence. Stakeholders, however, were more forthcoming on discussions around imbalance, highlighting as a topical example the inequity between health and social care visible during the COVID-19 pandemic. In the early months of the pandemic, provision and support for acute care in the NHS were afforded priority over care homes, contributing to the very high number of COVID-19-related deaths in the UK, which we believe represents a serious failure of understanding of the interdependency of different parts of health and social care. The newly developing ICSs provide a just-in-time solution to avoid this failure in future, as they provide the structure for communication and collaboration between providers.

Most research evidence for the ‘balancing multiple perspectives’ mechanism focused on the need for leaders to manage difficult conversations and mitigate the inevitable, and complex, forms of conflict that arose across organisations, specialisms and individuals, rather than identifying leaders as enthusiastic ‘change agents’. Although there was some evidence of strategies used by leaders to manage conflict (e.g. getting involved in steering committees or working groups of collaborative projects to reduce territorial behaviour or acting as ‘diplomats’ to mitigate tension), there remained only limited evidence of leaders successfully mediating conflict in integrated teams. Where this did occur, contexts that supported it, once again, included reciprocal trust between leaders and team members, where leaders were trusted to have the capacity to resolve conflict. Stakeholders’ experiences were more diverse here, with some agreeing that a leader’s role was to resolve conflict, whereas others felt that leaders should challenge teams to work out problems themselves. Those who believed that conflict or dilemmas needed to be resolved felt that this avoided uncertainty and made progress in system integration. For these individuals, the skill and art of leadership were seen to help take their team in a new direction. Without some resolution to dilemmas, they felt that it would be extremely difficult to manage system change for good or for bad, acknowledging that integration was not always positive across the system. Those who disagreed felt that successful leaders needed to be able to accept and be confident to work alongside the tensions, conflicts and ambiguities raised through cross-sector working. This suggested that rather than work towards harmony, leaders should accept and manage tension and conflict in ways that pragmatically mitigated negative outcomes to develop balanced partnerships where possible and appropriate. Finally, some stakeholders also questioned whether or not ‘balancing’ was the right term to use for this mechanism, as it suggested that it was possible to get the balance right. They thought that it was unlikely that integrated care leaders would be able to accommodate everyone’s perspectives but considered that it was important that everyone felt heard.

Working with power

‘Working with power’ was identified as an initial programme theory by the study’s stakeholder group. Although fewer than half of the research papers in the synthesis identified evidence to support it, evidence was more detailed than for most other mechanisms. Although stakeholders continued to support the importance of this mechanism, they perceived issues around power to be more complex and nuanced than depicted in the research literature. Indeed, stakeholder discussions around this mechanism focused on fundamental questions such as what power is, where it comes from and who legitimises it. Once again, although mechanisms have been separated here for the purposes of clarity, there is clear overlap between the ‘balancing multiple perspectives’ and ‘working with power’ mechanisms.

There was some research evidence that leaders were aware of power dynamics and used this awareness in different ways. Some used their power to promote their own professional agenda by limiting the involvement of others and some shared their power with other leaders in the system to set priorities, allocate resources and evaluate performance. However, even where there was a will to share power, an existing foundation of trust and honesty was needed between system partners. If those with less power (usually owing to the relative power of their employing organisations) felt that their views were not respected or overlooked, they could feel disenfranchised or threatened. This suggested that power sharing agreements could be difficult to manage and may be unstable and prone to being unsettled, depending on current priorities. This raises the question about whether or not power sharing is genuinely possible where partners from different organisations and sectors hold unequal power. Stakeholders reinforced this lack of parity of esteem between health and social care as a fundamental, structural and systematic issue that was unsurprising but nevertheless needed recognition and acknowledgement. The response to COVID-19, whereby people were transferred to care homes without testing to free up acute NHS beds was highlighted as an example of how the NHS and social care components of the system were regarded differently. Furthermore, in large integrated care systems it should particularly be questioned whether or not system leaders can know about all the power dynamics or processes to enable the appropriate use of power. Stakeholders identified a fundamental difference in organisational culture, which was perceived to be one of ‘command and control’ in the NHS and more locally driven or accountable in local authorities, with their locally elected democratic accountability.

There was limited research evidence of leaders recognising when colleagues in other parts of the system were in a better position to lead on initiatives than themselves. Where systems leaders used their power carefully, this could help the system progress successfully, encourage trust and respect within teams and foster a shared philosophy and vision. The concept of ‘borrowed’ power resonated with the stakeholders, whereby the implicit permission and support of someone with a clear decision-making power enabled leaders to support change. This permission was rarely seen as explicit but was more obvious when it was withdrawn, and activities were required to be stopped. Sometimes there were specific circumstances that prompted a leader to relinquish or share power (e.g. a requirement to access system/network development funding rather than necessarily for its own sake; dissatisfaction with an overly narrow network activity; or resistance to an unknown leader). These responses were presented in the research evidence as positive actions by leaders, though we question whether this is skilful or could be considered a ‘work around’. Furthermore, it is rarely reported how the shifting of power from the formal leader is managed: is it permanent, temporary, or acknowledged? This suggests that power operates through both people and working practices to indistinct degrees, reinforcing the view of stakeholders that working with power is more challenging to conceptualise than demonstrated in the evidence.

There was some research evidence that progress in the provision of integrated care systems could stall if leaders were unwilling to relinquish control. This was due to staff feeling undervalued, not co-operating with their leader, having reduced confidence to make decisions and innovate, or at worst, resigning. In comparison, research evidence stated that leaders who gave staff autonomy and trusted them were valued by staff. Leaders who delegated decision-making authority and shared leadership with others with more relevant knowledge made staff feel valued, leading to increased motivation, trust and confidence in the leader. This could be particularly important for ICSs, where leaders are likely to be leading teams and systems outside of their specific field of expertise. Indeed, stakeholders felt that power generally moved throughout the system, rather than operating from top to bottom and this could have a range of positive implications for leadership and notions of shared ownership and responsibility. Research evidence found leaders’ perceptions of their responsibilities were an important part of the context of how they used their power. When team leaders felt that their main responsibility was to the system’s ‘top’ management, they could seem to have no power of their own but instead be essentially a conduit for delivering the top management wishes with little adaption for local circumstances. As a result, they rendered the team powerless too. When a leader felt that they had a responsibility to their team as well as to ‘top’ management, they took the initiative to consult with team members, thus using their power to give power and autonomy to others. Although it may be considered weak to relinquish control, this did require a more skilful use of power. However, there was some evidence that sharing leadership was not always considered appropriate, for example, when other members of the team were unable to fulfil this role or when hierarchical leadership was considered necessary because of prescribed lines of reporting, or legal or policy challenges. Research evidence and stakeholder contributions showed that trust and ‘being known’ were also important contexts for being accepted and that new, unknown leaders may not be accepted.

Finally, stakeholders referred to the absence of this mechanism and the implications that this had on integrated care. They also highlighted the absence of the patient/service user voice throughout the research literature and the lack of power that patients/service users held within integrated care systems. Given that a primary aim of integrated care is to develop a patient-/person-centred approach, the absence of the patient/service user voice and the relative lack of power afforded to them is concerning.

Commitment to learning and development

Less than half of the research papers in this synthesis referred to this mechanism and there was very limited detail or consensus achieved across the studies that did discuss it. The research evidence and stakeholder contributions tended to focus on the importance of creativity, innovation and training initiatives, whereas discussion of learning and development rarely featured. Where research evidence did discuss learning, it was stated that leaders needed to demonstrate a commitment to personal learning, encompassing information sharing and reflective practice. In addition, multiple forms of interprofessional and interorganisational training and education programmes were highlighted and deemed important in supporting integrated working. Formal and informal networks between organisational partnerships, staff, and the community were demonstrated to be helpful in overcoming bureaucratic and infrastructural barriers to instigating change. Where teams had strong interprofessional relationships and where networks were strong and social capital was high, learning with and from other team members was more likely to occur.

There was a general sense in the research evidence and from stakeholder contributions that innovation and creativity were important components of leadership, whereby leaders who encouraged team members to develop and innovate maximised the potential of integration. However, detailed practice accounts were limited. Although identified as important by stakeholders, a tolerance for things not working and having the scope to ‘fail well’ was not apparent in integrated systems and this was seen to inhibit innovation. Lack of time, enthusiasm or team support were thought to contribute to leaders’ fear of thinking ‘outside the box’ and doing things differently. The culture of success and positive results perceived to be prevalent in the NHS is perhaps so embedded that an environment in which having the freedom to make mistakes is difficult to envisage.

Finally, there were other areas of the initial programme theory for which there was also limited evidence. For example, there was no specific mention of leaders acting as role models in the studies reviewed or in the stakeholder discussions, although there was some evidence of system-level leaders supporting and mentoring potential team-level leaders.

Taking a wider view

The research evidence for this mechanism was scant. Initial programme theory of this mechanism included reference to the importance of ‘political astuteness’, and although we found no research evidence for this, stakeholders advised that leaders could not operate without a sense of political leadership. This area, therefore, warrants further research. The research evidence did stress 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, although again, we found little explanation of how this happens. Stakeholders found the notion of strategically engaging with the ‘right people’ to be concerning, as they believed that this could result in leaders engaging only with ‘like-minded’ individuals. Stakeholders reflected that leaders sought ‘like-minded people’ when experiencing anxiety or uncertainty, and this is a plausible explanation given the size and complexity of ICSs and the political investment in their success. However, this could lead to a bias in outlook and undermine the diverse perspectives that leaders would be expected to adopt.

Research evidence found an influencing context of this mechanism was whether or not leaders had strong, pre-existing networks and a willingness to work with a wide range of individuals and organisations. This could also be a restrictive context and a barrier to this mechanism if leaders only worked within their pre-existing networks, restricting, or narrowing their view of the system. Another disabling context included the challenge of pursuing partnerships with several organisations and sectors simultaneously, especially where formal partnerships were more influential or beneficial than informal partnerships, for example, with the voluntary sector. Furthermore, where individual team leaders prioritised their own organisation, this could be a disincentive for collaboration with external partners. An additional context highlighted by the stakeholders was the importance of trust: a prominent characteristic of good leadership that ran throughout this review. Building trust in complex, multisector systems is likely to be time-consuming, and the research evidence suggested that it was highly dependent on individuals and their connections. The impact of organisational/system size or, indeed, the existence of financial incentives to support system transformation innovation was not specifically highlighted, although we postulate that this would influence the fostering and support of trusting relationships between leaders.

The paucity of evidence for this mechanism raised several questions, including:

• Because the NHS, social care, local authorities and other organisations are organised and governed independently, how likely is it that leaders will have genuine insight into the motivations and challenges of other organisations?
• How realistic it is that there will be a cadre of leaders who are able to do this?
• How are these leaders prepared, developed and supported to have the required experience and insight into the motivations and challenges of other organisations?
• If leaders have a background in one organisation (e.g. the NHS) and have been a senior leader there, how inevitable is it that they will be influenced by or favour this sector?
• Can integrated care disadvantage the perspective or involvement of smaller, less resourced and less experienced sectors who produce fewer senior systems leaders?
• Are education budgets for the development of integrated care combined and available to all system partners equally?

Clarifying complexity

The amount and detail of research evidence for this mechanism were less than the others, which limited the scope to refine our understanding of this aspect of leadership. Nevertheless, stakeholders maintained that the responsibility of leaders to clarify complexity in integrated care was important. It has been suggested that having clear directives at a strategic level from all agencies involved, as well as from government, is key to streamlining difficult processes,593 yet stakeholders reported that policy documents did little to address the day-to-day complexities of working in an integrated system and that there was no blueprint for leadership. Clarity of message was deemed an important leadership characteristic; however, this was not clearly or directly attributable to the ‘sensemaking’ strategies described in the initial programme theory. Furthermore, there was more research evidence about the absence of the mechanism, where leaders did not clarify and simplify specific issues, such as lines of reporting; financial structures and systems; roles and responsibilities of team leaders; and leaders’ reasoning and priorities. This lack of clarity left team members confused and frustrated and negatively affected the potential of integrated working. Although providing a balance between detail and oversimplification was thought to be a valuable leadership attribute in the initial programme theory, the complexity of system-level arrangements and a failure to translate these for team members appeared to overwhelm any practical attempt to negotiate this fine line. This potentially speaks of a lack of definition or fluidity of interpretation of integrated care. Leaders were given the difficult task of deciphering and then translating the changes in structures and ways of working imposed by new forms of integrated working. They were required not only to clarify complexity, but also present this complexity with nuance and intelligence to achieve positive outcomes.

The introduction of middle-range theories is used in realist synthesis to offer phenomena ‘conceptual currency’.594 This enables greater clarity of vision, and an opportunity to test the programme theories that have been developed. Utilising this approach, the findings above can be informed by theories of ontological security. Developed in social sciences,595,596 ontological security provides a sense of comfort and familiarity in a climate of distinct uncertainty. The new ways of working that integrated care encourages represent an uncomfortable and disruptive necessity of an environment that must accept complexity. Practitioners feeling disrupted by this complexity need leaders to provide clarification, in part to reassure them and in part to most efficiently communicate how an unfamiliar form of practice will work. Although integrated care is designed to make care more efficient, the associated complexities that are perhaps less visible, more nuanced or deliberately supressed (e.g. professional hierarchies, embedded tension, unconscious biases, political motivations) encourage complex consequences across the system. The need for this to be managed, or at least kept at bay, by clarity of message from those in positions of authority is another natural response to uncertainty. The difficulty with which this is genuinely provided by leadership, who are expected to recognise these hidden, embedded complexities and offer communication that is both clear and mindful of this is, therefore, considerable. Leadership that at least acknowledges this complexity and offers team members a sense of ontological security will demonstrate a level of sophistication that was absent in the research evidence.

Fostering resilience

Early in the study, stakeholders identified this mechanism as being more generic and less specific to integrated teams. They were not surprised that no research evidence for this mechanism had been identified. Stakeholders expressed concerns around the notion of ‘fostering resilience’ in leaders, including the suggestion that the term ‘resilience’ was code for ignoring or managing anxiety, without understanding the genesis of that anxiety. Successful leaders were deemed to be those who understand the necessity, practicality and political nature of providing leadership. There was also suggestion of a psychological dynamic below the surface of integrated working, which became overt in bullying and uncivil behaviours, and stakeholders felt that it would be useful to explore the cultures that leaders set around this. Although this provided further suggestion that leaders required higher level cognitive skills for integrated systems to function well, this also raised the question over whether or not resilience included an understanding of the difficulties associated with system change. If this is the case, it may be possible to suggest that the lack of evidence around being resilient is symptomatic of a failure on behalf of leadership and the literature to coherently explain what is happening during this shift towards integrated models.

The longitudinal nature of developing effective integrated care systems was also highlighted, with stakeholders noting that it was often a non-linear process. Resilience was, therefore, perceived to be a long-term endeavour. This suggested that ‘fostering resilience’ is a far more sophisticated requirement of leadership than the literature implies. It perhaps explains the absence of any evidence of fostering resilience in the research literature, as the notion must go beyond the superficiality of its appearance. Leaders may foster resilience by engaging in a range of behaviours and approaches, all of which combine to respond to the constant challenge of working in a shifting practice landscape.

Concluding remarks

In drawing this discussion to a close, we briefly consider how this review has contributed to the seven items identified as ‘a potential explanatory landscape’ for understanding complex programmes, in this case leadership of integrated care teams and systems.597 Throughout this chapter we have discussed the preliminary programme theories of leadership of integrated care teams and systems in detail, to provide potential explanations for the nuanced and complex way in which it is implemented. The review has found considerable variation in the resources available on leaders of integrated care teams and systems and in the reasoning and reactions of stakeholders. The third objective aimed to develop realist programme theories that explain successful leadership of integrated care teams and systems and these are presented in Table 5. These have been framed positively to address this objective, but it must be stressed that the evidence demonstrated unsuccessful leadership too. The study stakeholder group were adamant that they wanted the review to provide an accurate view of the challenges of leading integrated teams and systems, including the negative aspects. There was also considerable variation in how leaders worked and the environments/contexts in which they worked, which suggests that the programme mechanisms did not apply consistently (although the evidence available is not sufficient to see consistent patterns of CMOs). Contextual factors are likely to be highly influential in how leaders work with individuals and within specific institutions and infrastructures. The policy landscape for integrated systems is still undergoing development and this will influence the context for leadership with potential to support or hinder it.