Study design and conceptual basis
As with all complex social interventions, it can be assumed that leadership might work for different stakeholders in various settings in different ways. We therefore adopted a realist synthesis methodology39,40 to enable the identification of the key contextual characteristics and mechanisms that contribute to effective leadership practice in integrated care. This methodology involved developing and iteratively refining initial programme theories through both stakeholder consultation and evidence review.
Realist synthesis was developed as a means of applying realist methods to the evaluation of evidence.39 This may be of particular help when exploring a concept as fluid as leadership, where the processes of theoretical reasoning will enable an interrogation of systems and policy to a depth not possible with more conventional methods or systematic evidence reviews.1 Indeed, it has been suggested41 that systematic review is inadequate when the intention is to develop a fresh perspective, reinforcing a need for an inherently iterative, non-linear approach that performs multiple literature searches and constantly refines the evidence-based programme theories. Judging the literature should, in addition, be guided by how well it ‘fits’ into the process, rather than using predetermined quality criteria. This method also allows for the plurality of leadership strategies, the success of which seem often dependent on the unique combination of specific contextual conditions and associated actions.
Research question, boundaries, and scope
The research question identified for the review was:
What aspects of leadership of integrated teams and systems in health and social care work, for whom and in what circumstances?
As no unifying definition of an ‘integrated care team’ had been identified in the literature, we agreed to adopt the following definition of an ‘integrated care team’:
Integrated care teams consist of two or more teams that span multiple organisations, agencies or sectors within health and/or social care and interface directly and interdependently to address individual patient/client goals.
Similarly, as no single definition of an ICS existed, we defined it as:
Integrated care systems consist of the executive boards and senior leadership teams of two more organisations, agencies or sectors within health and or/social care which enable integrated care teams to work efficiently and address their goals.
These definitions were presented to and agreed by the expert stakeholder group. Thus, to be identified as an integrated care team or system and to be included in the review, any team/system in the literature needed to span organisations, be it across health settings (e.g. acute and primary care) or across both health and social care organisations. Initially, literature not relating to health and social care settings (e.g. the business and management literature) was excluded, although this was referred to at a later stage in the synthesis (see Stage 1b). Furthermore, to be included in the review, literature needed to discuss how to lead integrated care or how to develop leaders of integrated care, as opposed to focusing on the process of integration or whether or not integration in itself ‘works’. No limits were placed on the geographical location of the teams or on the nature of their client/patient group.
Searching the literature
Following realist synthesis methodology,39 two distinct search phases were undertaken for this review; stage 1 and stage 2. Owing to the complexities in identifying relevant literature for this synthesis, stage 1 was also further expanded into stages 1a and 1b.
Stage 1
Research literature
In consultation with information services specialists at both King’s College London (London, UK) and Kingston University London (London, UK), the following search strategy was developed:
“Integrat*” OR “multi-team*” OR “multiteam*” OR “cross-bound*” OR “cross bound*” OR “cross-organisation*” OR “cross organisation*” OR “cross-sector*” OR “cross sector*” AND “leader*” (Limiter: English language only, where available).
This search strategy was run in the following databases: EMBASE, Health Management Information Consortium (HMIC), Social Policy and Practice, Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, International Bibliography of Social Sciences, PsycINFO and Education Research Complete. A total of 1446 empirical research papers were identified, of which 532 were duplicates and were removed, leaving a total of 914 papers for review. These papers were divided between two reviewers (SS and SF), who read only the abstract of each paper to determine whether or not it was relevant to the focus of the review. At this stage, 848 papers were deemed not relevant and, therefore, were excluded from the review, leaving a total of 66 papers. These papers were divided between the two reviewers and read in full, as a result of which 43 papers were excluded,25,42–83 leaving a total of 23 papers.31,84–105
Grey literature
Grey literature relating to policy and organisational-based material was sought by searching Google (Google Inc., Mountain View, CA, USA), Google Scholar, government and other specialist websites [e.g. NHS Leadership Academy, Skills for Care, The King’s Fund, Advance HE (formerly known as the Higher Education Academy), The Institute of Healthcare Management, Social Care Online, NHS England and NHS Improvement]. Key words adapted from the main search strategy were used and included ‘leader’, ‘leadership’, ‘integrated care’ and ‘integrated system’. Enormous numbers of evidence sources were identified in the searches. Most were not relevant. Forty-one pieces of grey literature were identified and read in full by one reviewer (RH). This excluded 27 pieces of grey literature,8,9,106–130 leaving a total of 14.10,131–143
Stage 1 analysis
Stage 1a
A total of 37 papers (23 empirical research, 14 grey literature) were included in the first phase of the stage 1 search. These papers were divided between the three reviewers (SF, SS and RH), who each independently compiled a list of mechanisms or preliminary programme theories based on the papers they had read [to ensure consistency of approach, a small number of papers (n = 4) were read by all the reviewers so that the team could compare their analyses]. The reviewers then met together regularly to discuss their coding of mechanisms and any queries they had until agreement was reached. The following preliminary mechanisms were identified and accepted by all the study team (a short description of these mechanisms can be found in Table 1):
- supportive relationships and trust
- team working/collaborative working
- shared mission/vision/approach/purpose
- shared responsibility/ownership
- learning, development and innovation
- communication
- providing clarity
- balancing needs
- advocacy
- external liaison/consensus building.
| Mechanism | Description |
|---|---|
| Supportive relationships and trust | Leading integrated care teams requires skill in building high-quality interpersonal relationships, creating significant connections and establishing trust among diverse individuals and groups. Presence, mindfulness, engagement, empathy, team spirit and ownership are key characteristics of compassionate leadership. Dissatisfaction is communicated through appropriate feedback mechanisms to mitigate any negative impact on the team. For ICSs to work effectively, relationships need to be credible and resilient, with clarity in their collective focus. Supportive relationships in teams help overcome the scepticism and protectionism found among professionals regarding collaborative work while reducing duplication of services and visits in the community |
| Team working/collaborative working | Leaders work collaboratively with staff, patients, service users, politicians and citizens. Effective leadership teams work in a collegiate way and have a clear sense of collegiate responsibility. Leaders encourage the participation of all professionals and prevent resistance behaviours, ensuring that co-operation, trust, openness and fairness are instilled into the fabric of the service. Voluntary collaboration between NHS and local authority leaders develops a shared, system-wide approach to strategy, planning and commissioning and financial and performance management, and drives integration of care and services |
| Shared mission/vision/approach/purpose | Leaders of integrated teams are committed to a shared philosophy and common mission/vision/purpose for integrated services. Integrated services involve cross-boundary working with a wide and varied group of organisations. Leaders of these teams need to have insight into the motivations and challenges of other organisations, work through challenges in partnerships to develop collective solutions and look beyond reactive problem solving to take a longer term strategic view. Leaders oversee the implementation of the shared vision, ensure the right resources are available and regularly review the outcomes achieved. Shared vison can be used as a mechanism to focus effort at times of conflict and disagreement |
| Shared responsibility/ownership | Leaders of integrated teams share responsibility for financial cost and quality targets. This is enabled through collective engagement with risk sharing protocols that concern finances, resources and commitments, in addition to measures that monitor and review achievements. Performance management and outcomes frameworks are also used by leaders in local partnerships. Chairpersons and Chief Executive Officers develop a shared vision of the future for their organisation, ensuring that individuals throughout the system understand and accept it as something worth achieving. Shared responsibility for financial cost and quality targets has been deemed important to implementing successful models of leadership |
| Learning, development and innovation | Leaders generate continuous organisational learning and innovation, building adaptable and responsive team cultures. Aiming to improve themselves and those around them, leaders are inspirational and act as role models to encourage continuous learning and build a learning culture, offering opportunities for team members to develop and stretch themselves. Leaders have an interest in innovation and embrace evidence-based practice. They are skilled at leading complex, large-scale change through excellent facilitation and influencing skills. They use performance measures and data to inform design and planning and are also ready to support staff if and when the innovation does not succeed. Leaders create active partners rather than passive employees and, if nurtured appropriately, can encourage and support the individual development of leadership skills within their team |
| Communication | Leaders of integrated care teams possess an ability to listen and consult, adapt communication styles to suit the needs of the situation and audience, manage difficult conversations and read ‘what is not being said’ in an interaction. Leaders can challenge the status quo, manage conflict and have the willingness to engage in robust, open and honest debate. They engage others and can frame and reframe issues to influence how people see them, focusing team members’ attention to bring clarity and agreement to complex situations. Leaders promote high levels of communication and feedback upwards, downwards and across an organisation. They support their own team members to communicate effectively, equipping them to manage conflict and maintain a healthy work environment free of toxic behaviours and relational issues |
| Providing clarity | Leaders ensure that governance arrangements are clear and create synergy and cohesion by ensuring that rules are formed and a system of checks and balances is in place. Leaders also ensure clarity of leadership among their team members. Leaders translate complexity, making sense of disparate policy drives, legislation, performance requirements, regulatory systems and funding mechanisms. Leaders ensure that staff have a clear mandate for decision-making, with documents explaining how decisions are made and who has the authority to make them. This transparency enables stakeholders to see who has authority over specific areas to prevent confusion and enables them to navigate organisations with multiple decision-making bodies |
| Advocacy | Leaders act as advocates for improvement for their patient/client group, demonstrating effective communication with diverse individuals, groups and communities and a strong commitment to achieving positive outcomes. Leaders are enthusiastic local ‘change agents’, demonstrating full, visible and sustained support for service integration. Leaders may need to advocate for greater involvement of some organisations where there is the perceived need to change the historical power balance, e.g. between care homes and the NHS |
| External liaison/consensus building | Leaders have a strong focus on outcomes and the end goal in mind. They focus on the ‘bigger picture’ across their local health and care economy and on broader outcomes, acknowledging the importance of making strategic connections with leaders in other parts of the system and all other staff. They represent their team externally, demonstrating their effectiveness through data collection and evaluation and developing networks and linkages to promote the work of the team. Leaders are good at ‘deliberate’ engagement techniques and can take people on a journey with them, enabling them to see that not everyone will win. They also ensure that their team has the necessary resources and understands its customers so that it can exploit new opportunities |
Given the complexity of this review, an important component of the methodology was the inclusion of contributions from key stakeholders throughout the process. This process is recommended in realist methods,144 as learning what stakeholders know about an intervention and its reason for implementation is essential to understanding it. In this study, consultation and discussion with the stakeholder group was a vital part of the review process. Throughout the report we refer to their contribution to developing knowledge about leadership of integrated care teams and systems. Patient/service user and carer representatives were members of this group and therefore patient and public involvement (PPI) was embedded in all stages of the review. To ground the review in the lived experiences of stakeholders, separate consultation meetings were held during the project period with three stakeholder groups: those leading or working within integrated care teams and systems, patients/service users and carers receiving care from integrated services (PPI) and researchers with expertise in integrated care or realist methods. Most members of the stakeholder group were identified by searching on the internet for leaders of integrated care teams and systems. We were keen to find people who were currently involved in leading care delivery and overall system leaders. It was a challenge, as little detail is provided on NHS and social care websites. Some members were known to the research team in their professional capacity or were suggested as relevant by people we invited. Thirty-three people were invited by e-mail; four did not reply to the invitation and follow-up e-mail, seven declined (no longer in the UK, n = 1; retiring, n = 1; too busy, n = 4; unavailable on planned meeting days, n = 1) and three accepted the invitation but were unable to join any meetings and did not contribute to the review of study documents/findings by e-mail. Nineteen geographically dispersed stakeholders agreed to participate in the group and contributed to at least one meeting, consisting of six individuals with expertise in integrated care, eight with direct experience in leading integrated care teams or systems, two researchers with methodological expertise and three patient/service user and carer (PPI) representatives. Several members of the stakeholder group also had experience of both working in integrated care and leading teams or systems. The first stakeholder meeting took place at stage 1a in the synthesis, when the group met in person to discuss the preliminary mechanisms highlighted in Table 1. An independent chairperson led whole-group and small-group discussions, during which stakeholders were asked to comment on the mechanisms, including which they felt were most pertinent, any that did not appear relevant and any important mechanisms that may have been missed.
Overall, stakeholders felt that, although some of the mechanisms or programme theories were valid and relevant to integrated care teams and systems (e.g. ‘providing clarity’), others (such as ‘communication’ and ‘supportive relationships and trust’) were too general, and had already been identified in the generic leadership literature. They felt that the review needed greater interrogation to identify the components of leadership that were specific to integrated care teams and systems. For example, one potential mechanism that stakeholders felt was missing from the synthesis was around the use of power dynamics in teams and the way that leaders negotiate these. They therefore suggested that we include ‘use of power’ as a potential new mechanism and specifically search for any discussion of this in the literature (for more information on how stakeholders contributed to the development of mechanisms see Chapter 3, Stakeholder perspectives). Stakeholders were asked to forward any relevant papers that we may have missed on to us for review. Stakeholders also agreed that we consider exploring literature outside of health and social care, to see whether or not any other fields had identified potential theories around leading integrated teams and systems that may be applicable to health and social care. A subsequent search stage (stage 1b) was therefore undertaken.
Stage 1b
Given the difficulties that we had experienced in identifying mechanisms of leading integrated teams and systems in the health and social care literature reviewed, the scope of the review was expanded to include material outside health and social care (e.g. business and disaster management). We returned to the papers previously identified but excluded because they were based outside health and social care and also identified any possible new papers from their reference lists. Twelve possible new papers were identified at this stage.47,48,70,145–153 These papers were divided between two reviewers and read in full. Five of these papers were excluded and the remaining seven were included.47,48,70,145,147,148,150 Five additional papers were also forwarded on to us by members of the stakeholder group who felt that they would be useful inclusions in the review. These were again divided between two reviewers (SS and SF) and read in full. All five papers were included in the review at this stage.154–158
The additional 12 papers identified in stage 1b were divided between three researchers (SF, SS and RH) for review. Each reviewer independently compiled a list of mechanisms based on the papers they had read and also returned to their papers included in the stage 1a search and re-analysed these to look for any newly identified mechanisms. Thus, a total of 49 papers were included at this stage. The reviewers then met together again to compare their mechanisms and discuss their findings. In these discussions, they explored how their new mechanisms compared with those identified in stage 1a and explored ways in which the different mechanisms could be separated or merged to identify the components of leadership that were specific to integrated care teams and systems. The following 10 preliminary mechanisms were then agreed:
- inspiring intent to work together (this merged components of the ‘supportive relationships and trust’ mechanism with the ‘communication’, ‘advocacy’ and ‘team working/collaborative working’ mechanisms as well as incorporating newly identified aspects identified in stage 1b)
- enabling people to work together (this merged the ‘shared mission/vision/approach/purpose’ with newly identified aspects identified in stage 1b)
- strategic networking/focusing on the bigger picture (this merged components of the ‘supportive relationships and trust’ mechanism with the ‘external liaison/consensus building’ mechanism as well as incorporating newly identified aspects identified in stage 1b)
- commitment to learning and development (this mechanism remained similar to that identified in stage 1a but also incorporated feedback from the first stakeholder consultation group and searches conducted in stage 1b)
- clarifying complex processes (this merged aspects of the ‘providing clarity’ mechanism with newly identified aspects identified in stage 1b)
- creating balance between organisations and individuals/managing conflict (this merged components of the ‘balancing needs’ mechanism as well as incorporating newly identified aspects identified in stage 1b)
- use of power (this merged components of the ‘shared responsibility/ownership’ mechanism as well as incorporating feedback from the first stakeholder group and searches conducted in stage 1b).
- leader resilience (this was a newly identified mechanism, based on searches conducted in stage 1b)
- flexibility of leadership styles (this was a newly identified mechanism, based on searches conducted in stage 1b)
- use of public narratives (this was a newly identified mechanism, based on searches conducted in stage 1b).
These mechanisms were discussed and agreed by the study team. We then met with our international advisor to the study and expert on multiteam systems (MTS), Professor Stephen Zaccaro. The team discussed the process undertaken and the difficulties experienced by the reviewers in identifying specific mechanisms of leading integrated care teams and systems. Professor Zaccaro advised the team that ICSs could be conceived of as MTSs and suggested that the reviewers review the MTS literature for mechanisms of leadership of complex teams. The team, therefore, ran a search in Google Scholar for ‘leadership of multiteam systems’. Twenty potentially relevant papers were identified and read in full, as a result of which 14 papers were included159–172 and six were excluded.173–178 These 14 papers were divided between two reviewers, who, again, searched for any context–mechanism–outcome (CMO) configurations and for any mechanisms, contexts or outcomes that were not specifically linked in an explanatory way and added these into the preliminary mechanisms mentioned previously. Thus, a total of 63 papers were included in the stage 1 search (37 papers from stage 1a combined with 26 papers identified in stage 1b). All the included papers (and the mechanisms identified from them) are listed in Table 2.
| Paper | Inspiring intent to work together | Creating the conditions to work together | Taking a wider view | Commitment to learning and development | Clarifying complexity | Balancing multiple perspectives | Working with power | Fostering resilience | Adaptability of leadership styles | Planning and co-ordinating | General contexts | General outcomes |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Aitken and von Treuer84 (2014) | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||||||
| Aldridge139 (2016) | ✓ | ✓ | ✓ | ✓ | ||||||||
| American Medical Association85 (2015) | ✓ | ✓ | ||||||||||
| Amelung et al.134 (2017) | ✓ | ✓ | ✓ | |||||||||
| Appelbaum et al.148 (2007)** | ✓ | ✓ | ✓ | ✓ | ||||||||
| Baxter et al.135 (2018) | ✓ | ✓ | ||||||||||
| Baylis131 (2017) | ✓ | ✓ | ✓ | |||||||||
| Bienefeld and Grote145 (2014)** | ✓ | |||||||||||
| Bolden et al.157 (2020) | ✓ | ✓ | ||||||||||
| Burstow138 (2018) | ✓ | ✓ | ||||||||||
| Charles132 (2018) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||||
| Charles133 (2018) | ✓ | ✓ | ||||||||||
| Chartered Institute of Personnel and Development156 (2012)** | ✓ | ✓ | ✓ | ✓ | ||||||||
| Cooper47 (2016)** | ✓ | ✓ | ✓ | ✓ | ||||||||
| Covin147 (1997)** | ✓ | ✓ | ||||||||||
| Crosby and Bryson149 (2010)** | ✓ | ✓ | ||||||||||
| Croze86 (2007) | ✓ | ✓ | ✓ | |||||||||
| Daub et al.87 (2016) | ✓ | |||||||||||
| DeChurch and Mathieu159 (2009) | ✓ | |||||||||||
| deGruy88 (2015) | ✓ | ✓ | ✓ | |||||||||
| De Vries et al.167 (2016)* | ✓ | |||||||||||
| de Stampa et al.89 (2010) | ✓ | ✓ | ✓ | ✓ | ||||||||
| Fillingham and Weir10 (2014) | ✓ | ✓ | ||||||||||
| Ghate et al.158 (2013)** | ✓ | ✓ | ✓ | |||||||||
| Hartley154 (2018) | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||||||
| Horrigan90 (2016) | ✓ | ✓ | ✓ | |||||||||
| Insightful Health Solutions141 (2018) | ✓ | ✓ | ✓ | |||||||||
| Johannessen et al.163 (2012)* | ✓ | ✓ | ✓ | ✓ | ||||||||
| Jonassen169 (2015)* | ✓ | ✓ | ✓ | ✓ | ✓ | |||||||
| Jones et al.162 (2019)* | ✓ | ✓ | ||||||||||
| Kelley-Patterson91 (2012) | ✓ | |||||||||||
| Klinga et al.92 (2016) | ✓ | ✓ | ✓ | |||||||||
| Kugler et al.168 (2016)* | ✓ | |||||||||||
| Lazzara et al.160 (2019)* | ✓ | ✓ | ✓ | |||||||||
| Leadership Centre155 (2015) | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||||
| Luciano et al.172 (2018)* | ✓ | ✓ | ✓ | |||||||||
| Moore93 (2018) | ✓ | |||||||||||
| Morse150 (2010)** | ✓ | ✓ | ||||||||||
| Murase et al.165 (2014)* | ✓ | ✓ | ||||||||||
| Nieuwboer et al.94 (2019) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||||
| Outhwaite95 (2003) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||||
| Owen et al.161 (2013)* | ✓ | ✓ | ||||||||||
| Palazzo96 (2014) | ✓ | ✓ | ||||||||||
| Panzer et al.97 (2000) | ✓ | ✓ | ✓ | |||||||||
| Payne et al.98 (2019) | ✓ | |||||||||||
| Perks-Baker140 (2017) | ✓ | ✓ | ||||||||||
| Provider Voices143 (2018) | ✓ | ✓ | ||||||||||
| Rico et al.170 (2018)* | ✓ | ✓ | ||||||||||
| Robb and Gilbert99 (2007) | ✓ | ✓ | ||||||||||
| Schipper164 (2017)* | ✓ | ✓ | ||||||||||
| Social Care Institute for Excellence136 (2018) | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Shirey et al.100 (2019) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||||
| Smith et al.31 (2018) | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| South, Central and West Commissioning Support Unit142 (2019) | ✓ | ✓ | ✓ | |||||||||
| Stakeholder group feedback | ✓ | ✓ | ✓ | ✓ | ||||||||
| Sun and Anderson70 (2012)** | ✓ | ✓ | ✓ | ✓ | ||||||||
| Thomas and While101 (2007) | ✓ | |||||||||||
| Touati et al.102 (2006) | ✓ | ✓ | ||||||||||
| Wachel103 (1994) | ✓ | |||||||||||
| Weaver et al.171 (2014)* | ✓ | ✓ | ||||||||||
| West137 (2017) | ✓ | ✓ | ||||||||||
| Wheatley et al.104 (2017) | ✓ | ✓ | ✓ | ✓ | ||||||||
| Williams105 (2012) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||||
| Zaccaro and DeChurch166 (2012)* | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
A list of preliminary mechanisms was sent out by e-mail to the stakeholder group for review and then presented in full at the second in-person stakeholder group meeting. The independent chairperson again led small-group and whole-group discussions around how the mechanisms should be amended or merged. Stakeholders were specifically asked to challenge the mechanisms and were given space for questions to help generate deeper exploration of the key issues. By the end of this meeting stakeholders were content that the following mechanisms (generated as a consequence of literature searching and whole-group discussions) were pertinent to leading integrated care teams and systems (a short description of these mechanisms can be found in Table 3):
- inspiring intent to work together
- taking a wider view
- creating the conditions to work together
- clarifying complexity
- planning and co-ordinating
- balancing multiple perspectives
- working with power
- commitment to learning and development
- fostering resilience
- adaptability of leadership style.
| Mechanism | Description |
|---|---|
| Inspiring intent to work together | Integrated care teams and systems 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, and financial and performance management. Leaders are effective as advocates for integrated care and for inspiring intent to collaborate with staff across the system and outside it, at various levels. They have a supportive management style that promotes team cohesion, trust, respect, reciprocity and collaboration. Not only do leaders champion these values in their own conduct but they also promote them in their staff. They empower and inspire participation from all professionals, use ‘public narratives’ where appropriate and prevent resistance behaviours, ensuring that key values such as co-operation, openness and fairness are instilled into the fabric of the service |
| Taking a wider view | Integrated services involve cross-boundary working with a wide and varied group of organisations and people with a plurality of interests, goals, aspirations and values. Leaders of integrated teams and systems have experience and insight into the motivations and challenges of other organisations and focus on the bigger picture by acknowledging the importance of making strategic connections with leaders in other parts of the system. They use this knowledge to engage with other leaders, be convincing/persuasive in their communications with others, and work through challenges in partnership with other organisations by bridging language, thought-world and goal differences that may otherwise prove detrimental. This enables them to come up with collective solutions and to look beyond reactive problem solving by taking a longer-term strategic view. Their political astuteness is a necessary and beneficial set of skills that enable them to get things done for constructive ends. Consequently, the goals of the team are more likely to be achieved. However, political astuteness can also be used to pursue personal or sectional interests |
| Creating the conditions to work together | Different organisations, teams and individuals bring their own organisational, sectional or professional interests, ways of working and cultures. Leaders of integrated teams understand, are committed to and champion a shared philosophy, shared mental models and a common mission/vision/purpose for integrated services. Leadership is fundamentally more about participation and collectively creating a sense of direction than it is about control and exercising authority. They provide a clear narrative and direction for their team members to enable and encourage them to align their goals, have a shared focus and to engage in integrated working, rather than think about their own clinical teams, organisations or personal needs. They offer team members a sense of common ownership of the team and its reputation, are willing to delegate responsibilities and provide their colleagues with shared responsibility/accountability for financial, cost and quality targets. As a consequence, role defensiveness or ‘turf wars’ are limited, decision-making is assisted and effort becomes more focused during times of conflict and disagreement |
| Clarifying complexity | Many complex and challenging conditions are associated with integrated working, with unclear boundaries, structures and processes and different governance procedures and funding streams, but leaders can navigate the tension between certainty and uncertainty and translate this to their teams and/or systems. Leaders employ sensemaking strategies, in which they use a set of available artefacts to make the understanding of their message clear and internalised. They are successfully able to negotiate the narrow parameters between oversimplification and exclusionary detail, enabling team members to understand the complexity of disparate policy drivers, legislation, performance requirements, regulatory systems and funding mechanisms to ease working arrangements for the team. They do this by developing policies and initiatives that are easily communicated and understood, with documents explaining how decisions are made and who has the authority to make them. This prevents confusion and enables team members to navigate organisations with multiple decision-making bodies |
| Planning and co-ordinating | Leaders co-ordinate, strategise and serve as a liaison and boundary spanner between their team and the other teams in the system. They actively plan and synchronise the teams within the system, aiding the teams with their timing and executions of plans and helping them to organise intrateam processes with interteam processes and decision-making. When component teams struggle to perform their tasks because of high workloads, leaders can provide backup behaviours by prompting other component teams to provide help, shifting workloads to other teams or proactively offering to help with specific tasks. They employ smooth co-ordination processes that provide the necessary capacity to the whole system to move nimbly and synchronously. This strategising and co-ordination improves both team processes and system performance. However, system leaders must also be mindful of changing and competing demands and be able to switch quickly from the routine to the non-routine. Thus, leaders of systems devote time to ensuring system flexibility. If unexpected changes occur and contingency plans no longer seem appropriate, leaders decide whether to reconsider, abandon or adjust the original plan |
| Balancing multiple perspectives | There are historic power imbalances between health and social care (e.g. between care homes and the NHS) and between professional disciplines. Leaders ensure that there is balance between the organisational cultures, social mission and business aims of the organisations owing to having several specialist areas of knowledge and a good understanding of a broad range of topics. They are enthusiastic ‘change agents’ and demonstrate full, visible and sustained support for service integration. They advocate for those organisations that need greater power and are willing to have difficult conversations with colleagues across different organisations and specialisms and to deal with the uncertainty and ambiguity inherent in complex adaptive systems. This enables greater collaborative and equal working across organisations. Leaders are also able to create balance between professional hierarchies in the team and manage conflict between team members appropriately, working with, and negotiating with, many different stakeholders who have divergent values, goals, ideologies and interests. Leaders recognise tension and work through it with staff to develop a condition in which it is safe to challenge and discussion becomes healthy. A productive balance between harmony and healthy debate is maintained and a coalition is created, with a degree of actionable shared purpose |
| Working with power | Leaders have an awareness of power dynamics and know that the appropriate use of power within and across teams and organisations can be critical during times of uncertainty. Leaders are aware that power dynamics should be skilfully and intelligently negotiated and recognise that colleagues in other parts of the system are sometimes in a better position to lead on certain initiatives than themselves. In such circumstances, they are willing to shift power, migrate authority and relinquish control where appropriate, i.e. if better outcomes can be achieved. When leaders are unwilling to relinquish control, progress can stall. Leaders step aside, showing interest but not interfering or steering. They are also aware that tactics for reducing resistance to change based on threats, manipulation, or misinformation are likely to backfire. Leaders use referent power to bring their teams together (i.e. a charisma that makes others feel comfortable in their presence). This leads to higher team satisfaction during the process of change. Because referent power generally takes time to develop, this finding may highlight the importance of placing individuals who are known, liked and respected by employees in transition-related positions |
| Commitment to learning and development | Leaders have a strategic commitment to access external support and rapid learning with other like-minded systems. They are committed to reflecting on and personally learning from a variety of sources, through formal and informal networks, and to act as a role model for team members, encouraging them to also learn and improve. Leaders establish communities of practice for team learning and the pooling of knowledge. Although managers apply proven solutions to known problems, leaders are exposed to situations in which groups need to learn their way out of problems that could not have been predicted. Leaders recognise that training initiatives can increase component team members’ awareness and understanding of their knowledge structures, as well as their ability to regulate then improve the effective co-ordination of the whole system under dynamic circumstances. They have an interest in innovation and creativity, inviting feedback and embracing change and evidence-based practice for continuous improvement. They encourage team members to generate ideas and explore possibilities but also have a tolerance for things not working and learn how to fail ‘well’ |
| Fostering resilience | Those providing public services need to deal with increased demand, higher expectations from the public about service standards, hostility and psychological projections from the public and the media, often in the context of declining resources for public services. The pace can be relentless and the physical, intellectual and emotional demands very high. Successful leaders of integrated systems have both the personality and learned skills that foster high resilience, perseverance and an awareness of the importance of remaining empathic to the public while also resilient in terms of their own well-being. They put in place social support systems (both in and outside work) and attend appropriate training and personal development programmes to strengthen resilience. Leader stress is therefore reduced |
| Adaptability of leadership style | Leading an integrated team or system is difficult, given the complexities of moulding two or more organisations into one and the sense of loss or uncertainty that employees may experience as part of this. Collaborative leaders are able to adapt their actions based on the circumstances that they confront. They acknowledge that particular situations call for particular leadership skills and behaviours. Leaders align their styles according to the situation at hand, combining or switching approaches as necessary, changing strategy towards flexibility and the use of their tacit knowledge. This generates co-operation, cohesiveness and improved communication among group members |
Although some mechanisms (e.g. ‘inspiring intent to work together’, ‘creating the conditions to work together’ and ‘clarifying complexity’) were felt to be more relevant than others (e.g. ‘planning and co-ordinating’, ‘fostering resilience’ and ‘adaptability of leadership style’), the stakeholders and research team agreed that all 10 mechanisms should be explored in greater detail in stage 2 of the study.
The stage 1a and 1b search processes are shown in the flow chart in Figure 2.
FIGURE 2 Flow chart of stage 1a and 1b searches. (Figure not reproduced here; see the original article.)
Stage 2
After the preliminary mechanisms were identified in stage 1, a second stage search was undertaken to look specifically for any empirical evidence of these mechanisms. This second search comprised a search of the following databases: Social Policy and Practice, Education Research Complete, Social Care Online, Scopus, CINAHL, MEDLINE, International Bibliography of the Social Sciences, EMBASE, HMIC, PsycINFO and PubMed, using the following search strategy:
“Integrat*” OR “multi-team*” OR “multiteam*” OR “cross-bound*” OR “cross bound*” OR “cross-organisation*” OR “cross organisation*” OR “cross-sector*” OR “cross sector*” OR “Interorganisation*” OR “Inter-organisation*” AND “leader*” AND “Health” [Limiter: English language only].
Hand-searching of key journals identified by the study team and stakeholders (Journal of Interprofessional Care, Journal of Integrated Care and International Journal of Integrated Care) was also carried out by searching for the term ‘leadership’ in the online version of the journal. A total of 5673 papers were therefore identified at this stage, and all abstracts were read by two reviewers (SS and SF). A total of 5253 papers were excluded either because they were duplicates or because they were deemed not relevant, leaving 420 remaining papers. A further eight papers were also sent to us by the stakeholder group at this stage and added to the pool of documents for review, along with two papers that were picked up in the stage 1 searches but not stage 2; the 14 MTS papers identified in the stage 1 search; 11 papers identified through searching reference lists of relevant papers; and three papers recommended by the study co-applicants. This initially resulted in 458 possible papers, although 16 of these were inaccessible through library resources179–194 and not available through the British Library, which meant that 442 papers were divided between two reviewers and read in full. For this stage in the search, we were seeking only empirical research based in health and/or social care settings and a data extraction form was created and completed for each paper read. In line with realist synthesis methodology, conventional approaches to quality appraisal were not used.41 Rather, each study’s ‘fitness for purpose’ was assessed by considering its relevance and rigour.
Of the 442 papers read in full, 32 papers were included.84,92,98,102,105,195–221 The remaining 410 papers were excluded.10,25,42,44,47,48,51,53,54,59–62,65,75,78,89,91,94,95,97,100,101,104,106,107,110,129,149,150,153,159–172,174,222–585 Around this time, Professor Zaccaro informed us that he had recently completed a comprehensive review of all MTS papers and this had been published.586 To ensure that no key MTS papers had been missed in the stage 1 search, we searched the full reference list of this review for any empirical research exploring MTS in health or social care. No new papers were found.
To ensure consistency of approach, a third reviewer (RH) read all 32 papers included in the review to ensure that they met the inclusion criteria. Any CMOs identified from these papers were discussed with the third reviewer to ensure that there was agreement in decision-making. The third reviewer also read and reviewed a sample of the excluded papers to ensure that there was agreement around their exclusion.310,321,330,347,359,373,431,483,547,583 After team discussion, it was agreed that one originally excluded paper should be included in the review.583 Thus, at this stage, 33 papers from the original 442 papers were included in the review and 409 papers were excluded. The study team and stakeholders were informed of the number of papers included in the review at this stage and were asked for further advice on how to identify any additional papers. It was suggested that we search the Nuffield Trust website (nuffieldtrust.org.uk). After typing the word ‘leadership’ into the search box (filtered for ‘research’ only), three additional relevant papers were identified.22,587,588 Thus, a total of 36 papers were included at stage 2 of the synthesis.22,84,92,98,102,105,195–221,583,587,588 At this point, members of the wider study team were consulted, and they suggested that literature searching stopped, as the process had been comprehensive.
The evidence collected from these 36 papers was synthesised by drawing together all information on CMOs and comparing similarities and differences to build a comprehensive description of each mechanism and its role in the leadership of integrated care teams and systems. This was an iterative process throughout, identifying where mechanisms were triggered (or not), the context that enabled or hindered this and the resulting outcomes. Specific explanations of how CMOs were linked and recurrent patterns of CMO configurations within and across the papers were sought and recorded. These theoretically derived explanations were tested and refined using the findings of these empirical studies. All 36 included papers (and the mechanisms identified within each of them) are highlighted in Table 4.
| Paper | Inspiring intent to work together | Creating the conditions to work together | Taking a wider view | Commitment to learning and development | Clarifying complexity | Balancing multiple perspectives | Working with power | Fostering resilience | General contexts | General outcomes |
|---|---|---|---|---|---|---|---|---|---|---|
| Aitken and von Treuer84 (2014) | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Alexander et al.208 (2001) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Asakawa et al.209 (2017) | ✓ | ✓ | ✓ | |||||||
| Atkinson et al.207 (2002) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Axelsson and Axelsson210 (2009) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Balasubramanian and Spurgeon211 (2012) | ✓ | |||||||||
| Benzer et al.212 (2015) | ✓ | ✓ | ||||||||
| Best213 (2017) | ✓ | ✓ | ✓ | ✓ | ||||||
| Brouselle et al.214 (2010) | ✓ | |||||||||
| Carroll et al.215 (2015) | ✓ | ✓ | ||||||||
| Choi et al.216 (2012) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Chreim et al.217 (2010) | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Cohen et al.218 (2006) | ✓ | ✓ | ✓ | ✓ | ||||||
| Cramm and Nieboer219 (2012) | ✓ | ✓ | ✓ | |||||||
| Dayan and Heenan587 (2019) | ✓ | ✓ | ||||||||
| Dickinson et al.220 (2007) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Grenier583 (2011) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Karam et al.195 (2017) | ✓ | ✓ | ||||||||
| Kharicha et al.196 (2005) | ✓ | |||||||||
| Klinga et al.92 (2016) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Ling et al.197 (2012) | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||||
| Lunts198 (2012) | ✓ | ✓ | ✓ | ✓ | ||||||
| Nicholson et al.199 (2018) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Payne et al.98 (2019) | ✓ | |||||||||
| Rees et al.200 (2004) | ✓ | ✓ | ✓ | |||||||
| Roberts et al.201 (2018) | ✓ | |||||||||
| Rosen et al.588 (2011) | ✓ | ✓ | ✓ | |||||||
| Scragg221 (2006) | ✓ | ✓ | ✓ | |||||||
| Shand and Turner202 (2019) | ✓ | |||||||||
| Shaw and Levenson (2011)22 | ✓ | ✓ | ✓ | ✓ | ||||||
| Stuart203 (2012) | ✓ | ✓ | ✓ | |||||||
| Touati et al.102 (2006) | ✓ | |||||||||
| van Eyk and Baum204 (2002) | ✓ | |||||||||
| Williams105 (2012) | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||||
| Williams205 (2012) | ✓ | ✓ | ✓ | ✓ | ✓ | |||||
| Willumsen206 (2006) | ✓ | ✓ | ✓ | ✓ | ✓ |
These descriptions were then, again, e-mailed to the stakeholder group for review and discussed in detail at the third and final stakeholder meeting. Owing to restrictions in place as a result of the COVID-19 pandemic, a face-to-face stakeholder meeting was replaced by the online video conferencing software Zoom (Zoom Video Communications, San Jose, CA, USA). A member of the team led whole-group discussions, where stakeholders were presented with the evidence found for each mechanism and asked to help develop and refine these descriptions and explanations further, using their own lived, research or practice experiences. For more information on how the views of the stakeholder group were incorporated into the review during this final stage of the evidence synthesis, see Chapter 3, Stakeholder perspectives.
Figure 3 provides a flow chart detailing the stage 2 search processes.
FIGURE 3 Flow chart of stage 2 searches. (Figure not reproduced here; see the original article.)