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Inspiring different teams to work together is key to the successful leadership of any integrated health and social care system (ICS). However, little is known about how effective leadership can be supported and improved.

In England, ICSs are bringing together local NHS services and working with social care systems, local authorities, communities, and other groups, each with their own motivations. Leaders of ICSs therefore may be managing several professional teams with different goals and accountabilities. The challenges are not the same as in managing a team of professionals working towards a single goal.

ICSs are being rolled out across the UK and will soon be the new model of healthcare delivery. They are designed to put the person at the centre of their care. But there is little research on how leadership works (the mechanisms of leadership), and what makes it successful.

Research into successful leadership in health and social care mostly focuses on single teams and their tasks. This new study explored leadership of complex integrated teams and systems across health and social care. Working with a range of service providers and users, carers and researchers, the team reviewed the published evidence. They identified 10 mechanisms (such as balancing different perspectives, or working appropriately with power) which could influence the success of ICS leadership.

The researchers then searched for papers which either did or did not support the importance of these mechanisms. This allowed them to describe the influence of these mechanisms on ICS leadership.

Overall, the researchers said there was a lack of evidence on ICS leadership. Most studies referred to simple models of leadership and did not explore more complex teams and systems. They generally assumed the necessary skills for leadership are the same. The researchers argue that this assumption is not valid and that more research is needed to understand how to successfully lead ICSs.

What’s the issue?

The roll-out of ICSs is an important part of the NHS Long Term Plan. They aim to put people at the centre of their own care and provide a joined-up and coordinated service. ICSs are being designed to respond to local need, with commissioners sharing decisions with local providers about how to use resources, design services and improve people’s health in their locality.

ICSs will mainly involve the NHS, but they will work with social care, local authorities, private businesses, communities, and employers. Leaders will therefore work across several organisations and oversee a number of skilled professional teams, each with different experiences, expertise, and goals. Teams might have different ways of working and see people at different stages of treatment.

A successful ICS should deliver or coordinate safe health and social care services. This will take effective leadership. Researchers explored what it takes to lead an ICS successfully.

What’s new?

The study brought together a group of 19 people, which included ICS staff and leaders, researchers in integrated care, carers, people who use health and social care services. Together, the group reviewed research papers, relevant websites (such as The King’s Fund and NHS England) and policy documents. The process revealed 10 mechanisms likely to influence the success of ICS leadership.

The team then looked for evidence of these skills in practice. There was a lack of health and social care research into complex teams, so the researchers also looked outside of these areas (for example, at research into business management).

From 36 papers on leadership in complex teams, the researchers found evidence for 7 of the 10 mechanisms. They found that a successful leader was one who could:

  • inspire collaboration between teams - this was the mechanism most commonly explored in research
  • create the conditions to work together - a shared sense of direction and purpose allowed teams to align their goals
  • balance perspectives - leaders should encourage team members to appreciate others’ core skills and expertise, bridge differences in professional cultures and be mindful of the historic power imbalance which has kept social care on an unequal footing with healthcare
  • work appropriately with power - have the authority to drive an agenda, but also the capacity to share power where necessary to foster a sense of collective responsibility
  • take a wider view - in order to understand the motivations of the different teams
  • commit to learning and development - act as a role model for the team in this way
  • simplify complex ideas - for different teams, and define boundaries between different teams.

Some research described leaders who developed their own resilience by persevering through difficulties, remaining empathetic to the team and the public, and looking after their own wellbeing. This was initially thought to be an important mechanism but there was no evidence to support it.

The research revealed that leaders often draw on pre-existing networks of like-minded people. They want to work with people they already know and trust, but this can lead to a lack of diversity.

Why is this important?

Overall, most papers focused on the personal characteristics of an ICS leader rather than their role in an integrated team. The studies in the review did not generally address the complexity of the team, which is likely to make different demands on a leader. They generally assumed that leaders used the same tools or approaches, no matter how complex the team or system.

The research team argue that this assumption is not valid and more research is needed to understand how to successfully lead ICSs.

ICSs are collaborations between health and social care organisations and teams. Leaders need to balance the different cultures and aims of them both. They need to use their power appropriately to bring teams together, and then step aside as necessary to ensure progress is made. The question of how leaders of ICSs see and use their power was under-explored in studies.

Personal leadership characteristics are not enough to successfully lead an ICS. The complexity of these new systems requires a deeper understanding of the mechanisms identified in this research.

What’s next?

ICSs are designed to put patients and service users at the centre of their care, and ensure their care is joined up. Yet the researchers found no evidence that patients or service users had contributed to any of the research on such systems in the UK or elsewhere.

The researchers acknowledge that most patients, carers or service users will not see ICS leadership in practice. But gathering their views helps ensure that ICSs are meeting their objectives.

Much effort is being put into implementing ICSs. But this research suggests that people may not have the resources and support they need to lead them. There is a lack of practical guidance for ICS leaders on how to balance or address power between teams, for example. The mechanisms (rather than personal leadership qualities) that need to be in place for a complex team to succeed, are not well-researched.

Legislation on ICSs is expected soon. This should be accompanied by guidance, for example, on how to ensure that all teams are treated equally. The researchers hope their work will inform the legislation and implementation of ICSs. They suggest it should include tailored coaching programmes and education about these complex systems to help ICS leaders now and in the future.

You may be interested to read

This NIHR Alert was based on: Sims S, and others. What does success look like for leaders of integrated health and social care systems? A realist review. International Journal of Integrated Care 2021;21:4.

Advice from the NHS Leadership Academy for leaders at all levels: Our Research – Leadership Observatory.

A report from the NHS Confederation: The state of integrated care systems 2021/22.

Information from the Kings Fund: Our work on leading across organisational boundaries.

Advice on building ICSs from NHS England: Integrating care: Next steps to building strong and effective integrated care systems across England.

Funding: This study was funded by the NIHR Health Services and Delivery Research programme.

Conflicts of Interest: The authors have no relevant conflicts of interest. Reviewer Felix Gradinger was an advisory group member for this study.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

It will be challenging to lead an integrated care system, in which lots of different teams work together. Different teams have different ways of working, they can have different approaches to care and might use different terminology. How can one person align such different teams to a common goal?

We explored best approaches to leadership in such complex systems, and expected to include a larger number of papers. However, few explained how leadership worked; we were surprised at the lack of research in health and social care. We then looked at other areas, in which people lead complex, multi-professional teams. Even then, there was a surprising lack of evidence. We worked with many people with experience of leading complex teams in health and social care, and we identified 8 mechanisms that are reported to be necessary to lead an ICS.

The other big surprise was that we found no research that asked for the patient, carer and service user perspective. ICSs are designed to put people at the heart of their care. Their voices are needed to tell us whether they are working well and if not, how they should be changed.

Ruth Harris, Professor of Healthcare for Older Adults, King’s College London

ICS Leader 

This is a useful contribution to the development of leaders in the new health and care environment. It is relevant to me as a leader in an ICS and will inform my professional development and that of my colleagues.

The findings seem robust though I would caution against relying too much on evidence from merged business organisations. These mergers do not reflect the reality of working in more fluid, self-determined, ICSs. In these systems, leaders have a less formal mandate and rely more on leading through influence.

Rachel Leuw, Programme Director for Integrated Care, Royal Free London NHS Foundation Trust 

Researcher 

As an embedded researcher-in-residence working within an Integrated Care System, this study is highly relevant as we seek to mobilise formal and informal ways of knowing to inform system change in a time of unprecedented pressure, and rapidly changing contexts. In this context of uncertainty and complexity around what works, leadership skills described by this study are crucial for implementation of the inconclusive evidence base we have around the impact of integrated care. Most importantly, it aims to impact on leadership functions where health, social and voluntary care systems intersect hopefully breaking down organisational silos and reducing failure demand as a result.

This work is a crucial part of current national policy to establish Integrated Care Systems in the UK. Hopefully decision-makers involved in the implementation of ICSs will consider the existing evidence. They will need to invest in training and coaching for leaders at all levels.

Felix Gradinger, Researcher, Plymouth University, and an advisory group member for this study

Lived experience

The conclusions reached in the paper match my own life experience. By far the most important part of this report is the stakeholder review, which is most likely to throw up new ideas and perspectives. For example, one stakeholder suggested that power dynamics within teams should be explored; I agree with this suggestion.

For policy-makers, case studies could reveal a complex dynamic. Change is likely to be slow and incremental, and it will be difficult to attribute causality. Association is more likely.

However, planners and researchers may benefit more directly from the study. It provides cues and indicators for future research, and refinements of methodology. It may also close off some blind avenues.

Alan Hancock, Public Contributor, Milton Keynes

Clinician 

Much of the time in healthcare organisations, the theory and the reality do not match. It too often means that the way in which systems are implemented do not work.

This study provides insights into the way in which healthcare systems are led, against the reality of how systems work, with all of their complexities. Each system is unique, and a one size fits all method of leadership is not relevant.

The healthcare system is incredibly complex, with multiple departments, systems, and a wide range of staff. It was interesting that the voices of service users were not heard in the reviewed literature, as the health system is there for them. The researchers involved stakeholders in their analysis which gives an alternative perspective.

Rachael Kendrick, Antenatal and Newborn Screening Midwife, East Kent Hospitals University NHS Foundation Trust

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