How might leadership roles evolve in integrated health and care systems?

Report for the NHS Leadership Academy

This report explores some of the implications of the Long Term Plan and its supporting plans on leadership within local health and care systems, the roles that may emerge over time, and what knowledge, skills and support leaders need in the future. This report for health and social care leaders provides an overview of research carried out to better understand how leadership roles are changing in the sector, especially in collaborative and integrated health and care systems.

Key messages

• The NHS Long Term Plan (LTP) and the recently published health and social care White Paper – Integration and Innovation: working together to improve health and social care for all – that system leaders push forward a transformation agenda at a tremendous scale and pace that can feel overwhelming. It requires taking a long-term view to planning and prioritising certain areas at any one time.
• The LTP asks leaders to prioritise the interests of the wider system over those of any individual organisation, focus on prevention and health population management, and to think differently about how to address the wider determinants of health. Leaders must foster a significant cultural change if they are to succeed in all the above.
• Leaders must also contend with an LTP that places conflicting demands on them to deliver transformation whilst meeting a set of targets not necessarily aligned to a programme of change. The LTP also falls short in mapping out how to effectively engage with and develop valuable roles for local authorities and in addressing the severe workforce challenges facing health and social care.
• System leadership roles and governance structures need to continually evolve, but must do so in a way that is specific to individual systems and places.
• Effective system leadership can be facilitated or hindered by a number of interconnecting factors, particularly in relation to cultures, structures and approach, which can be grouped under the following five domains:
  • Clarity
  • Innovation and learning
  • Representative and balanced leadership
  • Connectivity and relationships
  • Resources and finances
• Effective system leadership relies on a composite set of capabilities, skills and behaviours. These include:
  • Leading through influence and empowerment, not hierarchy
  • Being politically astute
  • Having a flexible approach to how one works with the ‘rules’
  • Being able to think outside the box
  • Being able to build and communicate a clear narrative
  • The ability to live with ambiguity
  • Being able to hold and manage multiple strategies
  • The ability to make things happen
  • Being able to think ahead and plan for long-term objectives
  • The ability to cede power and resources
  • Having tenacity, courage and resilience
  • The ability to build strong relationships and understand the importance of networking and the psychology of change
  • The ability to understand one’s self
• Leaders told us that the following factors are important when supporting and developing system leaders:
  • Identifying future leaders early on
  • Having a varied menu of support and development programmes on offer
  • Focusing on system leadership rather than organisational leadership
  • Identifying and supporting leaders at all levels, not just the most senior
• Leaders identified several key features of successful leadership development programmes, including the need for offers to be locally owned and developed, and involving leaders from across a range of different sectors
• Leaders emphasised the important role they felt the NHS Leadership Academy could play in supporting locally developed system leadership programmes.

About this report

Thames Valley and Wessex Leadership Academy (now part of NHS South East Leadership Academy) commissioned the Social Care Institute for Excellence (SCIE) to undertake this research to further expand the understanding of the evolving roles of collaborative leaders across health and care systems. This research will inform the further development of multi-professional, collaborative leadership models across the NHS and targeted programmes of support. This report is based on a short review of recent literature on system leadership in integrated care systems and sustainable transformation partnerships (STPs), findings from interviews with senior system leaders, and a roundtable with a mix of national policy-makers, planners and leaders working in local health and care systems. It builds on work which SCIE undertook in 2018 on system leadership in integrated care systems and place-based leadership development. Quotes from these leaders are presented throughout the report along with case studies.

The context for this research is the publication of the NHS Long Term Plan which set out a new vision and delivery plan for the NHS, at the heart of which was a commitment that every area become an integrated care system (ICS) by 2021. ICSs seek to bring together local organisations in a pragmatic and practical way to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care and make shared decisions with providers on population health, service redesign and Long Term Plan implementation.

The Long Term plan also set out an ambitious aim to develop great leadership at all levels in the NHS and do more to nurture the next generation of leaders by more systematically identifying, developing and supporting those with the capability and ambition to reach the most senior levels of the service.

Further to the Long Term Plan, NHS England and NHS Improvement also published the Interim People Plan, which commits the NHS, in collaboration with its partners, to system leadership as the defining way in which local health and care is led.

This has now been followed by We are the NHS: People Plan 2020/21, which states:

In February this year, the Government published a White Paper – Integration and Innovation: working together to improve health and social care for all – which builds on the Long Term Plan’s goals on integrating care around the person. The White Paper will place ICSs on a statutory footing through both an `NHS ICS board’ (though this will also include representatives from local authorities) and an ICS health and care partnership. The ICS NHS body will be responsible for the day-to-day running of the ICS, NHS planning and allocation decisions. The partnership will bring together the NHS, local government and wider partners such as those in the voluntary sector to address the health, social care and public health needs of their system. The issues explored in this paper about systems leadership and new roles remain prescient to these new policy developments.

This research was conducted between November 2019 and March 2020, and was therefore completed just before the outbreak of COVID-19. To explore how leadership had adapted to the crisis within local health and care systems, NHS South East Leadership Academy asked SCIE to undertake a further case study to explore how leaders had responded within a specific local area and what COVID-19 might mean for future leadership roles. This involved interviews with four senior leaders in Hertfordshire and West Essex STP which were conducted between May and July 2020. View System leadership and COVID – Case study of practice.

Key questions of this research

• How will leadership roles and priorities evolve as a consequence of the NHS Long Term Plan?
• What factors act as enablers and barriers to how leadership roles must evolve?
• What skills, capabilities and behaviours will system leaders of the future require?
• What will support system leaders need in the future to fulfil these new roles?
• What are the key features of successful system leadership development programmes?
• How can the NHS Leadership Academy best support ICS systems to develop and support system leaders?

NHS Long Term Plan and the implications for system leadership

Conflicting views about the Long Term Plan (LTP) emerged from this research we conducted with system leaders. Some leaders suggested that the LTP articulates a healthy demand on taking a greater interest in the whole system, as well as focusing on prevention and health population management, rather than just treating individual people. Others were concerned that the LTP falls short on the key issues – with not enough emphasis being placed on the role of local authorities or the wider determinants of health. However, there was general consensus that the messages within the LTP signal a reassuring continuity from the centre and build upon the rational and objectives of STPs/ICSs. Finally, those we spoke to argued that the plan places conflicting demands on leaders to deliver transformation whilst meeting a set of targets not necessarily aligned to a programme of change.

Leaders identified a number of significant implications of the Long Term Plan for system leadership:

• Leaders must take the long view. The plan demands change at scale and at pace but leaders emphasised the importance of remembering that it is a ten-year plan, and consequently not everything should or could happen simultaneously.
• Subsequently – there is a need to prioritise. The Long Term Plan places too many demands on local systems and therefore leaders need to be able to prioritise a few areas at a time. Leaders suggested that prioritising certain areas that can be addressed quickly to demonstrate impact might be helpful.
• There is no single answer to achieve the Long Term Plan’s objectives. Leaders must take on a multifaceted approach to address current challenges and reach the plan’s objectives.
• Leadership roles need to be more system focused rather than organisationally tied. This means leaders must put aside the interests of any one individual organisation and focus on how the system can achieve the best outcomes of the overall population.It is imperative that system leaders become comfortable with working across the system, developing relationships across multiple organisations and sectors, and creating plans that involve the blending of traditional boundaries and partnerships. However, they must also deal with the challenge that they continue to be regulated against an old framework that asks them to put the interests of their individual organisations first.
• A significant cultural change is needed. For integrated care to become a reality, leaders need to change the mindset of whole organisations and sectors. This will require co-developing a common vision and priorities.
• There must be a shift in focus to overall population health rather than just on the individual health of each patient. It will require a considerable cultural change and leaders will need to embed the idea of supporting better health of whole population into all roles – not just clinical roles.
• Leaders must think and work differently to address the wider determinants of health. The traditional approaches to addressing and supporting population health have not worked so leaders must encourage dialogue with as many stakeholders as possible about new innovative approaches that are also more community led.

Limitations of the Long Term Plan

Whilst recognising the demands that the LTP places on leaders, those with spoke with also cited a number of limitations with the plan that they felt made it more difficult to achieve a more collaborative approach to public health management.

• The plan is not ambitious enough. Some leaders felt that that the LTP failed to bring new and innovative ideas to the table and it was therefore not forward thinking enough. Leaders shared concerns that the plan continued to reflect a siloed mentality embedded in national central government thinking.

• The current financial architecture and reporting requirements of the NHS are not yet aligned to the priorities of the LTP , and population health management in particular.

• The LTP does not have a clear accountability and assurance system in place. . Leaders told us that it was currently difficult to understand which individual organisations will be held accountable for many of the metrics set out in the LTP. Some suggested that system leaders needed to put an accountability framework in place to address this.

• The LTP has an overdetailed prescription of what ‘good’ looks like across many areas which is not conducive with bottom-up co-designed place-based leadership. For example, leaders mentioned that the plan’s over prescription of what should be delivered in relation to mental health services does not allow for a place-based approach to integrating mental health into population health-improvement strategies.
• Gaps exist in the LTP around social care and the role of local authorities. Alongside this, there is no equivalent long-term plan or national workforce strategy for social care.
• Some leaders are concerned that the LTP does not include a sufficiently coherent and integrated long-term approach to address the sector’s workforce challenges. Leaders cited the need to consider factors such as economic development, affordable homes, targeting workforces from other sectors forecast to see job losses (such as retail), ‘grow your own’ strategies, supporting and mobilising local communities to volunteer, or capital investment to halt the heavy reliance on a low-wage, low-skill, high-turnover workforce.

Integral leadership roles emerging

This research found that it was critical that leadership roles and governance structures continue to emerge and evolve. In fact, having roles and structures that are iterative has proved to be extremely important across many systems. These changes feel more like a continuation of an evolution already very much in progress. Leaders told us that it has been helpful when there is flexibility for roles and structures to develop alongside new relationships across organisations and sectors. For the NHS Confederation (2019), giving local areas the power to shape their own structures in ways that reflect local circumstances is an important facet in building effective system leadership. Leaders emphasised that the changes to roles need to be real, and reflect new thinking. Different job titles alone would not be sufficient.

Leaders stressed that new roles and governance structures that are created will and should reflect local circumstances, and will therefore be specific to individual systems and places. There are no models or specific roles that would necessarily be right for every system. There have been some common developments, such as the formation of Integrated Care Partnership boards at place level. Exactly who is on the board can vary widely, but membership generally includes local commissioning, primary care representatives, local authority members and voluntary sector representatives. Independent providers are less likely to be involved.

Some system leadership roles have become full time. Leaders discussed the advantages and disadvantages of whether leadership roles are full time or part time. For example, having a full time ICS lead executive can be important as it adds additional essential capacity to the role. However, the drawback can be that with full-time leadership roles, the sense can be created that the system is something separate rather than constituted of the organisations that are part of it.

Below we outline some of the new emerging roles that leaders spoke about. It is important to emphasise that no one proposed that these roles would or should emerge across all systems.

• More substantive ICS executive lead roles. Leaders spoke about ICS executive lead roles that were beginning to have clearer system-wide responsibilities. Examples were also given of where ICS leads were now being supported by a clinical lead and a finance lead, which gave them more time and space to focus on their key priorities and responsibilities. It also works well when the ICS lead has a background that generates credibility and therefore influence within the system. Currently they do not have formal accountability or authority.

• Independent chairs. ICSs are increasingly appointing independent chairs. They are taking a lead role in building relationships across the system and building a shared vision. Some systems have appointed council members as the independent chair – with the aim of becoming more democratically accountable for change, sustainability and deliverability.
• Joint roles between the NHS and the local authority. Leaders cited an increase in having joint digital, estate and workforce roles within the ICS executive team, as well as having joint children, mental health and learning disability posts. Leaders spoke about how joint roles reduce duplication and support the ‘working together’ agenda. Joint roles were also seen as helpful in shifting away from the commissioner/ provider split. Many saw it as an obvious step in the journey towards consolidating the public sector estate.

• Chief executives for each ‘place’ place’ rather than chief executives for each acute trust, who form part of the senior leadership team of the ICS. Some systems spoke about having Integrated Care Partnership directors that also sit within the ICS executive leadership team.
• Overall system finance lead for the ICS – taking a coordinating role around system finance and joint use of resources. The system finance lead takes a system-wide view of the finances across the whole ICS. They collect, analyse and report on financial data from across the whole system and support the individual finance leads across the system to work together.
• Having an ICS assurance team – with finance, performance and quality directors – to help ICSs who are increasingly feeling like they are being asked to take on an assurance role alongside their focus on transformational change.
• Having only one commissioning officer and one accountable officer for each place or ICS. Leaders also spoke about the need to scale back commissioning roles going forward.
• An overall lead on urgent and emergency care across the system – to support a more collective and coordinated approach.

• Leaders focusing on how to sustainably embed technologies. Leadership roles that enable the introduction of new technologies by ensuring clinical behaviour is changed in the use of technology.

• Leadership around managing and developing the workforce. Leaders argued that there is a real gap nationally and locally around the workforce and people plan, with the NHS having stripped its HR capacity over many years.
• Lead roles that are responsible and capable of running transformational programmes across the system. Leaders were concerned that the current focus was on system leadership and that the need for leadership roles that focus on transformation, organisational development, and system-wide programmes are being overlooked.
• Roles for data scientists are needed at the system level – who know what data to collect and how to collect it in order to develop a clear understanding of what is going on across the entire system.
• Leadership at the sub-system/ micro-climate level has been relatively less examined. There is a need to focus on pulling together clinical leadership at the ICP or sub system level. Leaders need to know how to work collaboratively with all the different relevant parties (PCN, county council, social care, voluntary and third sector, mental health services).

Key factors that can act as enablers or barriers to how leadership roles must evolve

Given the implications of the Long Term Plan and the shift towards systems working, greater collaboration and a focus on overall population health, we asked leaders what key factors act as enablers or barriers for system leadership.

This section sets out a number of factors, identified by leaders we spoke to, that either facilitate or hinder effective system leaders – particularly in light of how leadership roles need to evolve and the changes they need to enable. Many of these factors relate to current issues or developments that leaders identified as already taking place in the sector, particularly around culture and leadership approach. Other factors relate to gaps that have been identified and that need to be addressed urgently, or enabling factors that leaders would like to see transpire.

The factors fall under five key themes:

• Clarity
• Innovation and learning
• Representative and balanced leadership
• Connectivity and relationships
• Resources and finances

Enablers of clarity

• Having a clear and agreed-upon understanding of what different leadership roles entail, particularly in relation to system leadership. This includes a clear description of the responsibilities and objectives, as well as the skills and characteristics required to effectively fulfil the role. These descriptions must be set out clearly in the job specification. Leaders wanted a commitment from across the system (a role for ICSs perhaps) that going forward, job specifications would be written to reflect the principles of system-based working and leadership. Leaders emphasised that only after mapping out the necessary skills and qualities that system leaders will need can the right support be developed and provided for leaders.

• System leaders having a clear narrative around their vision and purpose. It is important for leadership boards (ICSs and ICPs) to have clarity of purpose and well-defined objectives. This should be centred around a shift from solely focusing on treating illnesses, to one that focuses on wider population health, and from organisational objectives to system-wide objectives. This narrative must be communicated directly and concisely to all staff across the relevant organisations within an ICS.
• A clear understanding on what should be done at the system level and what should be done at the place level. System leaders need to work with stakeholders across the system to develop consensus and clearly define the areas of work that are best addressed at system level, place level and neighbourhood level.
• Working on and demonstrating quick wins alongside spending time setting up governance structures. Developing the architecture and governance arrangements of STPs/ICSs is time intensive and requires significant resources. A lot of time is spent talking about governance and reviewing and changing arrangements – which is necessary – but can result in very little transformational work getting done to begin with. It is important to look for initial quick wins or to continue work that was already in progress. New governance arrangements can lead to losing momentum that was there prior to the new governance structures. It is important to widely disseminate evidence of these quick wins and clearly demonstrate progress.

 Barriers of clarity

• Not having the time and capacity to undertake system work in addition to one’s day job. This was directly related to the previous point about job specifications. Leaders struggled to find the time to do systems work because it is not often officially specified as being part of their job. This issue is only compounded for staff further down the chain. Leaders need to create the right culture that gives people permission to work on system transformation work whilst still being accountable to their statutory organisation. This will involve developing a sense of system perspective for every leadership role (and perhaps all roles) – where it is part of one’s day job – not an added bonus. As mentioned above, leaders must be intentional in creating that space – being prescriptive within job descriptions in terms of what that will look like.

• Not having clear definitions for integrated care, place and system – that are agreed upon and understood in the same way across the relevant sectors (e.g. local authorities, health, third sector and communities).

• Lack of system (ICS) statutory status; clear lines of accountability; and a full understanding of system objectives and remit. Leaders can find it challenging that the system’s remit is not clearly defined in law and that system work often involves having to be accountable to multiple line managers that can add further complexity.
• Recruitment challenges due to lack of clarity on job stability and misconceptions around what system leadership jobs entail. The continuous changes taking place within the NHS can discourage potential candidates from applying for system leadership roles. People worry that the role may cease to exist as soon as they start. Negative perceptions of what system leadership entails also create challenges. System leadership roles are not always seen as being particularly productive or producing substantial or tangible outcomes. Furthermore, there is no clear career pathway for some leadership roles (clinical leadership roles in particular). More work must be done to shape a clear message that shows the value and impact of system leadership roles.

Enablers of innovation and learning

• Maintaining the right balance between innovation and delivery. Leaders argued that organisations and systems where there is found to be most progress tend to be those where the permission for staff at all levels to try new things is embedded within the culture. This enables people to use what they learn from leadership development programmes and to experiment with new ways of working. Leaders must encourage a less risk-averse culture that gives people the space to try things even when there is a chance it may not yield the desired results. A value must be placed on the opportunity to learn no matter the outcome. For integrated care and systems working to succeed, the space for innovation and failure is necessary.

Identifying useful new roles for colleagues whose current roles are threatened by changes. Leaders recognised that many roles might be threatened or phased out as all the transformation work takes place. There is a need to therefore identify new roles that might be required in this evolving system-wide architecture and support colleagues who may find their current roles threatened to explore these new opportunities and learn new useful skills. This is particularly imperative when thinking about the system transformational work needed – because those who see changes as a threat to their role will not support or enable change.

Barriers of innovation and learning

• Not focusing on the adoption and roll-out of digital innovations. Digital technologies have an important role to play in system transformational work. However, this will require building up the appropriate skill set within digital transformation leadership teams – including a nuanced understanding that introducing new technology requires changing cultures and behaviours. Leaders spoke about how many digital developments end up not being used because not enough focus was paid to the pathways and behaviours that needed to change to be able to use the digital innovations effectively.

Enablers of representative and balanced leadership

• Wide sector representation. Leaders told us it was important to ensure that the individuals who take up system leadership roles (at ICS and ICP level) represent different sectors, including health, local government and the voluntary sector. This can lead to a wider sense of ownership over the change agenda – and a wider reach in terms of valuable stakeholders who can be brought on board.

• Joint roles shared between the NHS and local authorities and more broadly having leaders that have the capacity to work across organisational boundaries. This enables strong connecting relationships between individuals playing key leading roles across different parts of the system. Joint roles are also a good way to address overlaps between these organisations and reduce duplication.
• Adopting a triangular approach to leadership roles. Having the following three elements represented by leadership roles was cited as being incredibly important:
  • executive function (directors of finance or leadership etc.)
  • lay function (bringing accountability and the external perspective)
  • clinical function (which traditionally has always been represented by doctors but should extend further).
• Drawing the right balance between place and the wider system. System leaders must allow for individual direction and strategy at place level alongside an overall aligned vision for the whole system. This necessitates recognising and being comfortable that a bottom-up approach will be messier than a top-down approach. Connected to this is ensuring that the right balance is struck between focusing on developing the best structures for wider system leadership – and creating micro-climates with strong leadership at place level or for different work streams.

• Leadership roles attracting colleagues from mental health and community settings. Leaders suggested that colleagues from a mental health and community sector background are well placed to take up system leadership roles. They are well versed in having to work and build relationships and networks across organisations and sectors – and therefore have a lot more experience in systems working. They are therefore an integral resource to tap into and should be encouraged to apply for system leadership roles.
• Public Health playing a greater role. If the ambitions of the Long Term Plan are to be achieved and to reflect the emphasis being made on population health management and prevention, Public Health England needs to be expanded and given greater prominence and visibility.

Barriers of representative and balanced leadership

• The top-down approach within the NHS is at odds with a place-based focus. The NHS tends to operate as a national, corporate entity – with the centre directing strategy. This does not align itself well with place-led working. Leaders say that there is a disconnect between national and regional priorities and locally driven plans. Whilst leaders acknowledged that the direction of travel appears to be moving towards more local freedom, they also accepted that reverting to a top-down approach can happen quickly when things get difficult. Therefore, there is a need to stay vigilant and for leadership roles to support and reflect the right balance between place (and neighbourhoods) and system.

Profile of system leaders:

• Narrow sector background: Leaders talked about the narrow and specific sector/organisational background of many leaders – who tend to come from the NHS or local authorities – and can tend to view the system through the lens of their past organisation and experiences.
• Insufficient clinical representation: The lack of sufficient and wider clinical representation in system leadership, beyond doctors. For example, general practice, pharmaceutical or nursing representation is lacking.
• A lack of diversity in certain leadership roles, for example system leadership roles within general practice do not seem to attract female applicants.
• The balance between NHS and local authority leaders within an ICS: ICS members from local authorities can feel outnumbered by colleagues from NHS organisations. In many places, the role local authorities have played in STPs/ ICSs has not always felt equal or meaningful. Where local authorities have been part of a much more equal partnership with the NHS – with local government leadership embedded at the heart of the ICS leadership – it has been incredibly powerful and valuable.

• The lack of voluntary, community and private sector representation in system leadership and governance structures:
  • Local politicians are critical but often overlooked by systems leaders. Leaders suggested that behind the most successful systems leaders, are usually well-engaged and supportive politicians.
  • Voluntary and community sector engagement is variable across systems. Whilst there is a common understanding that engagement with this group is critical, systems can find it challenging to involve them in their work. There are not many examples where the NHS uses its weight and capabilities to train leaders within the community or third sector. Leaders we spoke to felt that the NHS was missing out by not supporting and utilising leadership potential in these sectors. ICPs are beginning to engage more effectively with the voluntary sector, however there is still room for improvement. Leaders spoke about finding it challenging to know which individuals or bodies from the voluntary sector to invite to the ‘table’, as it is a very diverse and populated sector with no clearly defined representatives.
  • Private sector (particularly independent providers): Leaders thought it was necessary for system leadership to engage with the private sector as it is a key stakeholder in the provision of health and social care. However, they felt there is still a lot of resistance to such engagement and that the NHS has not tapped into the resources and expertise available. Leaders also recognised the need to be careful about how such engagement takes place and who to engage with. There is a need for a more nuanced set of principles that can guide further engagement, dialogue and collaborative working with the private sector.
  • Widely constituted leadership boards. Leaders did note that the drawback of leadership boards being widely constituted is that they can become large and unwieldy and consequently they can become difficult forums for decision-making. Having a smaller system leadership executive board for decision-making, with other boards underneath this for particular areas or themes can be more effective.

Enablers of connectivity and relationships

• Making decisions in the interest of the whole system and the capacity to work across organisational boundaries. Leaders must constantly be working to break down organisational barriers and create a model of collaborative leadership that seeks views from those beyond the ‘room’. Leaders must focus on building relationships and finding solutions with all relevant stakeholders. To do so leaders need to fully understand the context and logic of system work. Leaders must be supported to develop the confidence to talk about system-wide working and harness the language around system working fully.
• Frequent face-to-face meetings. Leaders talked about the importance of how relationships are developed. It is imperative to invest the necessary time and energy into forming meaningful relations with colleagues across different organisations and have regularly scheduled face-to-face meetings. Creating safe spaces to air difficult histories amongst stakeholders was also cited as being incredibly important.
• Transparency and sharing of information. Leaders talked about the need for an open-book approach to information across a system, working together to understand the individual positions of constituent organisations and the overall system context to develop appropriate and relevant strategies and plans.
• Having a strong support system around leaders. Leaders emphasised how powerful having a range of networks are in making system leaders feel supported. This not only involves the supportive roles around system leaders within the infrastructure of the ICS or ICP, but also the support system leaders have in their constituent organisations (particularly when someone steps up from their current role in an organisation to carry out a lead role within an ICS or ICP). Leaders spoke in particular about the importance of opportunities to cultivate networks on the back of leadership development programmes.

• Narratives must be co-developed and owned by as many stakeholders and organisations as possible. Whilst having a clear narrative is crucial, leaders must focus on ensuring all relevant parties are engaged and included in developing the ‘system’ narrative. A narrative may also evolve and be iterative. But leaders talked about how if one builds agreement and consensus around narratives by jointly developing and owning it with others, and filter the narrative through the lens of place, then the narrative still has continuity and legitimacy.

Barriers of connectivity and relationships

• Reconciling organisational sovereignty and lines of accountability with system priorities and system working. Accountability and statutory arrangements have not evolved alongside the development of STPs/ICSs, and they still sit with organisations. Conflict can often arise between an organisation’s priorities and system priorities. System leaders need to create the right culture that allows people to operate in the system transformational space whilst also being accountable to their own statutory organisation. Leaders must develop a narrative where doing both are seen as complementary activities rather than competing ones that are in tension with one another.
• Local authorities work in a profoundly different way to the NHS, and have different pressures and working cultures. These differences can cause tensions that system leaders must address, including:
  • The NHS, being a national mandated service, continues to operate with a corporate entity at the centre directing strategy, while local authorities work in a more independent way.
  • Governance structures differ between the two with local authorities having elected members and ICSs appointing their members. Local authorities also hold all their meetings in public. Consequently, local authorities do not always see ICSs are being transparent and accountable.
  • Local authorities have been working on a prevention and wider population health agenda for a long time. However, leaders we spoke to reflected that there can be a tendency for the NHS to act as if it has discovered this agenda itself and that rather than collaborate with local authorities on a joint agenda, it is trying to own and drive it itself. This can be further exacerbated by differences in opinion on what the approach on prevention should be, and the fact that the Long Term Plan does not appropriately focus on social care.
• Individual places and local communities identifying with the ICS footprint: There are often very different ‘places’ under one ICS banner which may all have very separate identities. Work must be done to get everyone to understand the benefits of working alongside or within this new larger footprint that many ‘places’ may not have identified with before.

Barriers of resources and finances

• To develop the right ICS governance structures and roles, significant resources and funding are required. Unfortunately, these are limited. Different systems have taken different approaches to resourcing system leadership roles and governance structures, such as accessing available transformational funding or having individual organisations within a system contribute money or personnel to support the roles. However, the lack of sufficient resources can prevent systems from putting the right governance structures and roles in place.
• The majority of systems are facing significant financial and operational pressures. Short-term pressures can take system leaders away from the long-term transformational care work needed.

The role of regulators

Leaders spoke about the important role that regulators must play in enabling system leaders to carry out their role effectively. Oversight and assurance continue to take place at the level of individual organisations, and often runs counter to the ethos of system working. There are encouraging examples where ICSs are beginning to have direct conversations with regulators and discussing system-wide solutions to emerging issues, rather than multiple bilateral conversations taking place between individual organisations and regulators. Some leaders also talked about regulators needing to step up and regulate ‘system performance’ so that ICSs can focus on transformation and improvement.

Capabilities, skills and behaviours that are needed to ensure leaders are able to deliver on the NHS Long Term Plan’s priorities

A key theme to emerge from our research was that the core skills, capabilities and behaviours that system leaders now require are very different from what leadership roles demanded in the past. A number of essential capabilities, skills and behaviours were identified by those we spoke to and outlined below.

Leading through influence and empowerment, not hierarchy. System leaders do not have formal powers and accountability and therefore rely on a different kind of authority. Leaders must be able to negotiate and encourage people to reach consensus. They must be able to understand other people’s perspectives and motivations and use that information to enlist their support and cooperation. They need to know how to influence people who they do not manage, and how to negotiate with people who can walk out of the room. Furthermore, leaders should empower colleagues and partners – supporting them to become active participants in transformational change.

• Politically astute. Leaders must have a good understanding of the relationship between health and local authorities, health and social care, and health and regulatory and national bodies. Each one is complex and full of subtle yet significant dimensions that leaders must understand and master.
• A flexible approach to how one works within the ‘rules’. Leaders are being asked to change their ways of working and operate in a different way, whilst still having to be held accountable to old frameworks. Consequently, it can feel like one is failing to prioritise interests in the way that the rules, legislation and regulations continue to ask for. Leaders must therefore be comfortable and ready to work around the existing rules, not fully ignore or break them.
• Leaders must be able to think outside the box, beyond the specified limits of their role, organisation, sector, or geography. Leaders must be prepared to work beyond their statutory responsibilities and obligations. They must be agile and continually switch between performance work and transformation work. They must be thoughtful and curious about how different parts of the system work and connect together. Leaders must try to think independently.

• Leaders need to be able to build and communicate a clear narrative. They must be able to promote this narrative and align everyone behind a single vision. Leaders need to know how to talk to different audiences and understand what language to use to connect with a particular audience.
• The ability to live with ambiguity. Leaders work in an ever-evolving context and must navigate mixed messaged from the centre. In particular, leaders have to be comfortable with the transitional nature of current governance arrangements, as governance structures and leadership roles continue to evolve.
• Leaders must be able to hold and manage multiple strategies at any one time and feel comfortable having to multitask and deal with complexity.
• Leaders must have the ability to make things happen, while being reflective and mindful of the intended and unintended consequences of decisions made and actions taken. They must be confident and proactive, and focus on doing things as well as talking about things.
• Leaders must be able to think ahead, and continually plan to meet long-term objectives, whilst simultaneously having to address short-term problems. They must have skills for strategising and prioritising so as not to spend all their time focusing on the immediate issues.

• Ability to cede power and resources. The NHS Long Term Plan demands that leaders start to concede things for the wider good. That can sometimes be detrimental to the interests of their own organisation and to how their performance might continue to be evaluated. The ability to cede power and resources (and to understand the need for this) can be a difficult psychological barrier to overcome. Leaders require humility, a lack of ego and a willingness to take risks, in order to be willing to switch from having power over people to sharing power with people.
• Leaders will be held to account for quality and performance (which is now much more target driven) whilst still driving forward transformational work. Leaders will therefore need to be tenacious, courageous and resilient, especially when not hitting their targets, to hold their nerve and carry on with the transformational work needed. This involves self-awareness and developing good support frameworks around oneself.
• Leaders with good people skills. Leaders need to be good at building strong relationships based on trust and mutual respect. To do so, they need compassion and empathy and the ability to understand different perspectives. Similarly, leaders need to value politeness, consideration and patience, as well as the careful use of language. Furthermore, they need soft skills such as:
  • networking
  • understanding group dynamics
  • understanding the psychology of change
• Leaders need to have a good understanding of themselves. It is important to be able to self-analyse and understand one’s own strengths and weaknesses, and subsequently recognise who to bring in to complement one’s skills and attributes.

Supporting and developing system leaders

We asked leaders what they felt could be done to better support and develop systems leaders. Leaders suggested that it was important to focus on succession planning and identify future leaders early on in order to help develop the pipeline and provide early support. Setting protected time aside for leaders to continue their learning and development on an ongoing basis was seen as important, alongside an understanding that leadership development was an ongoing journey and not a one-off ‘programme’ to take part in. Having a varied menu of support and leadership development programmes on offer was imperative to suit different learning styles and preferences.

Leaders highlighted the importance of peer-to-peer support, coaching and mentoring in particular, to focus on areas such as reflection, understanding different perspectives and managing emotional health and wellbeing (once again stressing the need for a variety of approaches to all these mechanisms). However, leaders emphasised that whatever format leadership development or support took, it must focus on system leadership rather than organisational leadership. Furthermore, to enable change effectively, leaders need to develop skills around transformation and programme management.

Leaders we spoke to also placed a strong emphasis on the need to identify and provide support to leaders at all levels, something which both the NHS Confederation (2019) and The King’s Fund (2019) call for. Many we spoke to felt that leadership development and support programmes tended to focus solely on the most senior leaders and often missed out on middle management and team leaders. All leaders throughout an organisation’s hierarchy need to have a system-wider perspective to help embed system-wide working and change the culture of an organisation throughout.

Leaders focused in particular on what they felt were the key features of successful system leadership development programmes:

• Leadership development offers must be sensitive to the needs of the local system – rather than a one-size-fits-all offer. Locally-owned and developed programmes were therefore favoured. Some leaders spoke about the importance of an ICS having a separate academy that focuses on development initiatives that are aligned with ICS ambitions.
• Development programmes that involve staff from different sectors (health, social care, local government, police, education etc.). Having locally-developed programmes that cut across these sectors contributes towards breaking down barriers between organisations and sectors rather than exacerbating silo working. Leaders were concerned that different sectors still tend to have their own siloed national development programmes.

• Creating forums where leaders across different systems who carry out similar roles and functions can come together to share learning, experiences and ideas.
• Leadership development programmes that work with an entire team or invite several participants from a particular system work well because it leads to learning becoming more embedded within the organisations or systems that participants return to.
• A problem-solving approach to leadership development programmes was seen as incredibly effective. Leadership development programmes that include a practical element where participants are applying their learning to practical challenges better equip participants to implement their learning in their own job. Leadership development programmes that take a place-based approach and focus on addressing issues particular to the local system or geographic area are particularly effective and create more sustainable results.

• Leaders who design the system leadership development programmes should also be directly involved in the governance and leadership teams of the ICS. This ensures that programmes are designed to align with ICS ambitions and strategic direction.
• Leadership development programmes that are designed to empower leaders at all levels and encourage them to feel like they have agency and can contribute effectively towards the changes that need to happen to enable more integrated working.
• Leadership development programmes that focus on innovation and improvement and encourage participants to try new ways of doing things and to become less risk averse within their own local systems.
• Leadership development programmes that continually evolve and improve in response to learning from each cohort. Leaders also spoke about the need to become more sophisticated and systematic in collecting data from innovative leadership development programmes to evidence impact and secure further funding to expand and roll out similar programmes.

Role of the NHS Leadership Academy

Leaders felt it was important not to have competition between local leadership development programmes and programmes run by national bodies, and talked about the need for a supportive and collaborative relationship. They emphasised the important roles they felt the NHS Leadership Academy could play in supporting locally-developed system leadership programmes:

• Empowerment role
• Guidance role
• Evaluation and quality assurance role
• Mapping and signposting role
• Contribute to ICSs
• A convenor

Empowerment role

To nurture and encourage systems to take ownership over their own leadership programmes.

Guidance role

To provide expertise, resources and direction to local systems running their own development programmes. In particular help ensure system leadership programmes are focusing on system leadership rather than on organisational leadership, and not on leadership alone – but on leadership that leads to improvement.

Evaluation and quality assurance role

To help assess whether local programmes are successful and are providing a return on investment. Help local development programmes set up effective evaluation processes.

Mapping and signposting role

To focus on tracking what development programmes exist within each system and help signpost and connect what is already in place. Take on an oversight role to ensure programmes and support models are reinforcing one another – not at odds with one another.

Contribute to ICSs

Be more actively involved in STP/ICS’s spaces – and contribute to ongoing conversations and live problem solving.

A convenor

The NHS Leadership Academy could play a role in bringing different bodies together that focus on leadership development across other sectors. For example, coordinating with organisations like the LGA and ADASS on how to bring leaders together across the sectors through training and development and consequently better support the integration agenda.

References

Charles, A., & et al. (2018). A year of integrated care systems: reviewing the journey so far. London: The King’s Fund.

Frimley Health and Care. (2019). System Operating Plan 2019 20. Frimley: Frimley Health and Care.

Institute of Public Care. (2018). Stepping up to the place. Part B: evidence review. Oxford: Institute of Public Care.

The King’s Fund. (2019) Leading for integrated care: ‘If you think competition is hard, you should try collaboration’. London: The King’s Fund.

NHS Confederation. (2018). Letting local systems lead: how the long-term plan could deliver a more sustainable NHS. London: NHS Confederation.

NHS Confederation. (2019) Defining the role of integrated care systems in workforce development: a consultation. London: NHS Confederation.

NHS, England. (2019). Designing integrated care systems (ICSs) in England. London: NHS England.

NHS England. (2018). Mechanisms for collaboration across health and care systems. London: NHS England.

NHS England. (2019a). The NHS Long Term Plan. London: NHS England.

NHS England. (2019b). The NHS Long Term Plan – a summary. London: NHS England.

Rachael Loftus, & Ian Holmes. (2019). Development of the West Yorkshire and Harrogate 5 Year Strategy for Health and Care: West Yorkshire and Harrogate Health and Care Partnership.

Social Care Institute for Excellence. (2018). Leadership in integrated care systems. In (pp. 28). London: Social Care Institute for Excellence.

West Yorkshire and Harrogate Health & Care Partnership. (2018a). Engagement and consultation mapping. Wakefield: West Yorkshire and Harrogate Health & Care Partnership.

West Yorkshire and Harrogate Health & Care Partnership. (2018b). Memorandum of Understanding: West Yorkshire and Harrogate Health & Care Partnership.

Further information

Download

• How might leadership roles evolve in integrated health and care systems?