Leadership in Integrated Care Systems

The huge ongoing transformation in how health and social care in the NHS in England is being planned, structured and delivered - in the form of the new Integrated Care Systems (ICSs) - will have a huge impact on the role that leadership plays in healthcare. This seismic shift will naturally create challenges for leadership in ICSs, while there is an onus on the NHS to help support these transformational changes. In the Interim NHS People Plan, created by NHS England and Improvement in 2019 the authors state: ‘We must do more to foster system-based, cross-sector, multi-professional leadership, centred around place-based healthcare that integrates care and improves population health.’ A leadership challenge, indeed!

There is already lots of guidance to support the changes towards collaborative leadership, such as the Kings Fund’s many publications and the NHS Leadership Academy’s Leadership for System Change course. This specifically looks at the ‘practical, place-based support for ICSs, to build collaborative system-wide leadership thinking and practice, supporting pan-sector teams working across organisational boundaries on complex issues relating to ICS strategic priorities.’

In this article we’re going to take a look at the various leadership challenges in the new ICSs and how the NHS Long Term Plan and the health and social care White Paper can help support these leaders and systems to work together for better patient outcomes. We’ll also look at how joined up healthcare and building collaborative leadership will create a more holistic approach to health and care.

Challenges for leaders in integrated care systems

There’s no doubt that there will be challenges for leadership in ICSs in the coming months and years – not least the need to foster new ways of working across health and social care, dealing with the backlog of the pandemic and severe workforce challenges, as well as caring for an ageing population with long term conditions.

The writers of the NHS Long Term Plan and the health and social care White Paper readily admit that it may feel overwhelming for leaders as they start to transform the healthcare agenda at scale and pace, however, by taking a long term view in planning and by prioritising certain areas, they feel this will help tackle challenges.

The role of leadership in ICSs is vitally important to their successes – and one of the main challenges leadership faces is the focus on prevention and population health management, while also thinking differently about how to address the wider determinants of health to create cultural change.

In the King’s Fund 2019 paper, ‘Leading for integrated care: If you think competition is hard, you should try collaboration' the team interview chairs and leads of ICSs and the then transformation partnerships (STPs) and found out about ongoing challenges. They found that - while these leaders were clear about which skills were needed to create an ICS - they had concerns around ‘governance, accountability, the pace of change and on how far a collaborative and voluntary approach can be the key to success.’

So, leaders are facing challenges of new territories and across system providers, and a backlog of appointments due to the pandemic, and need therefore to be thinking differently about care in order to ‘create a network of change agents across a system to drive forward system thinking in practice.’

Evolving role of leadership in ICS

The many challenges to leadership in ICSs mean that these roles will need to evolve and change. The authors of the King’s Fund 2019 paper, ‘Leading for integrated care’ agree: ‘As these systems evolve, strong leadership is needed to bring NHS, local authority, private and third sector organisations together.’

A report created by the Social Care Institute for Excellence’s (SCIE) for the NHS Leadership Academy looks at the specifics of the evolving role of leadership in ICSs, which explores some of the implications of the Long Term Plan and its associated plans for leadership.

Collaborative leadership is something that the new ICS leaders will need to buy into. Indeed, the Long Term Plan highlights how vital the evolving role of the leader is, when it says: ‘ICSs will agree system-wide objectives with the relevant NHS England & Improvement regional director and be accountable for their performance against these objectives. This will be a combination of national and local priorities for care quality and health outcomes, reductions in inequalities, implementation of integrated care models and improvements in financial and operational performance. ICSs will then have the opportunity to earn greater authority as they develop and perform.’

With the Long Term Plan asking leaders to ‘prioritise the interests of the wider system over those of any individual organisation’, and asking them to focus on prevention and population health management, leaders will have to evolve to think differently about how to provide healthcare. Indeed, leaders are encouraged to ‘foster a significant cultural change if they are to succeed.’ All part of the evolving role of leadership within ICSs and the basis of collaborative and joined up care as a vision for the future.

Necessary skills of ICS leaders

Successful and collaborative leadership in ICSs will require a raft of skills and tools in order to apply and develop learning around systems across the health and social care space.

As the Kings Fund says: ‘Better integrated care requires the dilution or destruction of the long-standing barriers between hospitals, GP practices, community services and social care, with the health system also working far more effectively with local government in tackling the broader determinants of population health.’  Therefore, in order to get to this place of balance, ‘system leadership’ is required, which is defined as ‘the creation of collective leadership across all of that, for the benefit of the whole.’

There are many skills that leaders in the ICSs will need, set out in five key domains: clarity; innovation and learning; representative and balanced leadership; connectivity and relationships; and resources and finances.

The Social Care Institute for Excellence’s (SCIE) report for the NHS Leadership Academy 'How might leadership roles evolve in integrated health and care systems?' sets out a capabilities, skills and behaviours which are needed for effective system leadership, which 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

So, quite a set or skills is required in order to foster collective accountability!

The NHS Academy’s course, ‘Leading for System Change’ has been created to develop the capacity for system-wide thinking and action within an ICS, bringing together ‘system leadership knowledge and principles with their practical application to enable colleagues to work together on deep-seated, complex issues that form part of the ICS’s priorities. Well worth looking at if you want to learn about supporting real change in your ICS and help ‘changes in the way people think, the way they behave and the way they interact, with better outcomes for local populations.’

Building collaborative leadership for a more holistic approach to health and care

It’s clear that the approach to building a more holistic approach to health and care lies in successful and collaborative work, and that in turn, encouraging collaborative leadership will bring benefits for local populations and outcomes for patients.

There’s no doubt that ICS leaders must pursue collaboration to be successful. Indeed, the NHS ‘Integrated Care Systems: Design Framework’ states: ‘The collective leadership of ICSs and the organisations they include will bring teams with them on that journey and will command the confidence of the NHS and other public sector leaders across their system as they deliver for their communities. The level of ambition and expectation is shared across all ICSs – and there will be consistent expectations set through the oversight framework, financial framework national standards and LTP commitment – with ICSs adjusting their arrangements to be most effective in their local context.’

The NHS Confederation also has an Integrated Care Systems Network and its 'Clinical and care professional leadership in integrated care systems' states ‘All systems will have innovators, experts and respected leaders within the ranks of their multi- disciplinary clinical and care staff. They should be identified, and their skill set harnessed to ensure the ICS can flourish.’

So, as we have explored in this article, there are real challenges for leaders of Integrated Care Systems, however, there are also strategies and plans available to help support them as they develop new ways of working  With the necessary skills - ICS leaders will provide collaborative leadership, leading to a more holistic approach to health and care.