Parts of this report have been reproduced or adapted from Harris et al.1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
Parts of this report have been reproduced or adapted from Sims et al.2 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
Rationale for the review
This chapter sets out the background and rationale for the study and explains our purpose in conducting a realist synthesis of leadership of integrated care teams and systems. It explains the history of integrated care and discusses the reasons for identifying the attributes that facilitate effective leadership of these systems. Our approach, which focuses on identifying and understanding the mechanisms through which leadership of integrated care works and the necessary contextual circumstances,3–5 is informed by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards for realist syntheses,6 providing justification for utilising realist approaches in the study of a complex system and subject.
The organisation of health and social care in England is moving rapidly towards integrated models. NHS policy documents, such as the Five Year Forward View7 and the more recent Long Term Plan,8 have emphasised this shift, with the strategic intention of building upon existing cross-sector interdependence between the NHS, social care, local authorities, communities and employers. To ensure success in existing collaborations and integrated systems, a range of development needs has been identified, including leadership.9 Leadership of integrated teams and systems is a complex, multifaceted concept, lacking a strong evidence base. In particular, there is little understanding of how effective leadership across integrated health and social care teams and systems may be enacted, the contexts in which this might take place and the subsequent implications for integrated care as a whole.10
Our realist review of leadership of integrated care teams and systems responds to this first by comprehensively mapping the evidence base and, second, by applying realist principles in the interpretation of the literature to identify the key characteristics that comprise effective leadership practices. Realist synthesis is a particularly useful approach when exploring a concept as fluid as leadership, as the processes of theoretical reasoning that are required by the approach enable an interrogation of systems and policy to a depth not possible with more conventional or systematic evidence reviews.
Objectives and focus of review
This review developed and refined the programme theories of leadership of integrated care teams and systems in health and social care, exploring what works, for whom and in what circumstances. It has produced recommendations for policy-makers, health and social care leaders, managers and clinicians to help them design work systems and leadership development initiatives to support effective leadership of complex multisystem services.
Formal objectives for the review were as follows:
- to investigate who are the leaders of integrated care teams and systems and what activities contribute to their leadership roles and responsibilities
- to explore how leaders lead/manage integrated care teams and systems that span multiple organisations, agencies and sectors
- to develop realist programme theories that explain successful leadership of integrated care teams and systems iteratively through stakeholder consultation and evidence review
- to identify the development needs of the leaders of integrated care teams and systems
- to provide recommendations about optimal organisational and interorganisational structures and processes that support effective leadership of integrated care teams and systems.1
These objectives were designed to enable the analysis of established perspectives around integrated health and social care, leadership, and these elements in combination. The next section provides background on the development of integrated care, exploring how and why effective leadership is important.
Defining integrated care
The cross-cutting nature of integrated care suggests that a single definition is problematic. These systems serve a complex and diverse range of stakeholders. Expectations regarding the purpose and objective of integrated care are likely to differ, sometimes significantly, although there have been useful descriptions that enable the identification of a range of central characteristics that constitute an integrated care team and system.
In answer to the question ‘What is integrated care?’,11 a number of commonly used definitions have been presented. These include a health system-based definition, a definition from the perspective of health and social care managers and a social science definition. Although these emphasise a common need for co-ordination of people and services around a shared goal of improving health outcomes, the patient perspective seems both the most illustrative and the most important:
I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.
In addition, The NHS Long Term Plan8 explains the purpose of an integrated care system (ICS) as follows:
An ICS brings together local organisations to redesign care and improve population health, creating shared leadership and action.
They state that an ICS includes the integration of primary and specialist care, as well as social care and mental health services.
Historical development of integrated care systems
There are, in addition, universal factors that have been identified as driving the implementation of ICSs, including reduction of fragmentation, continuity of care beyond the hospital setting, patient centeredness and shared managerial vision.13
The initiatives included in Figure 1 broadly combine to lay the foundations for what is now known as integrated care in the UK context, suggesting a long held, gradually refined intention to integrate health and social care services across a range of disparate contexts. To further understand how integrated services have reached their most recent iterations, an exploration of the relevant policy developments may assist. It is possible to discern how the shift towards a recognition of the value of integrated working and systems has come about, and how integrated care has been adopted as a concept and goal across governments and periods of time.21 Figure 1 provides a selected chronology of the main policy interventions that have prompted a move towards integrated systems of health and social care in England. In addition, the boxes on the right-hand side of Figure 1 offer examples of the terminological development of integrated care22 and how this type of working has been referred to across different periods of time.
FIGURE 1 A selected chronology of policy interventions prompting integrated systems of health care. CQUIN, Commissioning for Quality and Innovation framework; ICP, integrated care pilot; PBC, practice-based commissioning; PCG, primary care group. (Figure not reproduced here; see the original article.)
The emergence of integrated care in England can be viewed as a consolidation of the devolution of the NHS across the country accompanied, perhaps paradoxically, by greater centralisation in the form of NHS England. In addition, integration is seen as a means to protect resources through joint working and as a more effective method of delivering care to an ageing population with the associated rise in long-term conditions.23 While the combination of these elements is important, there is also a distinction to be made between a universal recognition that integrated care is representative of progress and the complex realities that face sometimes radically different locations and patient/service user populations. Although this offers some insight into the development of integrated care, the difficulty around conceptual definition remains. The complex variation of health and care provision and populations across the country has been acknowledged and offers some explanation of why consensus has not and perhaps should not be reached. The following excerpt24 explores this complexity, while providing key principles that can be broadly applied to integrated care:
Integrated care takes many different forms. In some circumstances, integration may focus on primary and secondary care, and in others it may involve health and social care.
The authors further state that:
A distinction can be drawn between real integration, in which organisations merge their services, and virtual integration, in which providers work together through networks and alliances.
And conclude that:
The most complex forms of integrated care bring together responsibility for commissioning and provision. When this happens, clinicians and managers are able to use budgets either to provide more services directly or to commission these services from others.
Achieving a combination of real and virtual integration, alongside delivery and commissioning, is a challenge for leadership. In this complex context, implications for leaders’ merit addressing. They must respond to the dynamic perceptions and realities of integrated care in their activities and behaviours. This highlights a need for a processual view of leadership to accommodate the complex and constantly changing relationships and circumstances inherent in integrated systems. The next section offers examples of leadership organisation in contemporary integrated care models.
Leadership of integrated care
Leadership is a complex concept, with many differing definitions, including those which seek to distinguish it from management.25 Yet, despite these differences, there is a consensus that leadership involves the direction of a group towards shared goals, wider organisational values, a vision and objectives and the management of ongoing change.26,27 Effective leadership is claimed to be a key element of well-co-ordinated and safe health and social care,28–31 and ineffective or absent leadership has been linked to reports of failures in care leading to patient/service user harm.32 Existing research on leadership tends to be based on the premise that leaders provide guidance for single or uniprofessional teams33,34 and overlooks the complexity, intricacies and inevitable tensions that arrive in leading ICSs. These leaders do not influence just one organisation or professional group, but instead often work between several organisations across primary and secondary care, health and social care, publicly funded services, the not-for-profit sector and private businesses. Leaders of ICSs will, therefore, require different skills from their predecessors,24,35 yet there is currently little understanding of what these may be, what the mechanisms for effective leadership across integrated care teams and systems might be, the contexts that might influence it or the nature of the resulting outcomes.10
The NHS Long Term Plan8 described the governance of ICSs as being inclusive of the following:23a partnership board, drawn from and representing commissioners, trusts, primary care networks, local authorities, the voluntary and community sector and other partnersa non-executive chairsufficient clinical and management capacity drawn from across constituent organisationsa named accountable Clinical Director of each primary care networka greater emphasis by the Care Quality Commission (CQC) on partnership working and system-wide quality in its regulatory activity, so that providers are held to account for what they are doing to improve quality across their local areaNHS providers to take responsibility, with system partners, for wider objectives related to a) use of NHS resources and population health; and b) longer-term NHS contracts with all providers, including clear requirements to collaborate to support system objectivesclinical leadership aligned around ICSs creating clear accountability to the ICS.
Although this suggests that there are leadership structures in place, questions concerning how leaders can operate effectively in these structures are timely. Although The NHS Long Term Plan8 states that leadership should be aligned with ICS structure, the collective governance additionally described builds largely on existing leadership processes, providing adaptive reaction rather than a more directive development of leaders of and for integrated care. Thus, while there is evidence to suggest that strong and supportive leadership and joint governance are important to the successful implementation of integrated care programmes,36–38 we do not know the characteristics required to provide this strong and supportive leadership, how this may look and under what circumstances this can be most effectively enabled.