Rethinking leadership styles for integrated care systems

Working in systems, it is easy to make assumptions about what people already know and what is meant by specific words. Ambulance leaders will have a very different interpretation of what is meant by an emergency to that of a politician or a financial controller.

Many assume that they can know what the other is thinking but without effective communication and board development leadership styles that are truly integrated, the reality more often than not turns out to be very different.

We find that leaders often feel the need to wear one hat when making decisions on behalf of an organisation, which they then switch for a different hat when contributing to the system.

Just because something is called a system, that doesn’t mean it necessarily operates as a system should. The point about system or integrated leadership is that what is good for the organisation is what is good for the system, and vice versa.

Previous attempts at integrating systems

Integrated care boards (ICBs) draw on many of the same principles espoused by Michael Heseltine in the 1980s.

He argued that incentivising leadership across organisational boundaries and funding tied to community outcomes rather than spreadsheets, led to a clearer focus on the receiver of the services rather than those responsible for delivering them.

So, will ICBs represent a decisive step forward in the hitherto turgid journey of place leadership, or yet another valiant but ultimately flawed attempt to reset place leadership?

Heseltine was an early pioneer of urban regeneration, having been tasked with the government’s response to inner city riots in the likes of Brixton and Toxteth. His idea was to focus on partnerships and places, with the establishment of Urban Development Corporations and programmes like City Challenge and the Single Regeneration Budget. In the late 90s, New Labour embraced a very similar approach with New Deal for Communities, Urban Taskforce, Neighbourhood Renewal Fund – the list goes on.

Earlier programmes tended towards physical regeneration (buildings, roads etc.) while later ones focused more on social regeneration. Most had some positive impact on the places they operated within, though by common consent – backed up by no shortage of academic research – many failed to meet their core objective of sustainable regeneration.

Unperturbed, the coalition government of 2010-15 launched its own Regional Growth Fund and of course in recent years we’ve had the promise of ‘levelling up’, accompanied by yet another sizable pot of government resource.

It’s interesting to reflect on the impact of this approach over the decades. With so much money, expertise and goodwill, why didn’t they all have the transformative effect they promised? One of the primary challenges facing local systems is that they are governed, funded and regulated differently. This often fosters very different organisational cultures, which is difficult to align with the unified, strategic objectives of a geographical scheme. This in turn creates a perverse incentive to focus on inputs (buildings, schemes, funds) rather than sustainable outcomes (early intervention, education, innovation) and so most schemes come and go with only tacit reminders of their long-term impact.

Tempered optimism

Despite the monumental challenges facing public sector leaders, we remain optimistic – but our optimism is tempered by an important caveat. The significance of effective systems leadership has been tacitly and occasionally explicitly acknowledged as the lodestar of place leadership throughout the canon of initiatives set out earlier. Indeed, several policies have been predicated on it. But despite some notable success stories, we contend that systems leadership is not yet embedded in the managerial culture of public sector leaders and if the potential of ICBs is to be truly realised, that is going to have to be addressed.

GGI has built a formidable knowledge bank on systems leadership over the last decade or so. This knowledge is drawn from a combination of the practical experience of working within local systems across the length and breadth of the country, underpinned by empirical research and modelling of managerial behaviours and trends.

Based on this knowledge, we’ve put together an exciting new programme designed to help public sector leaders exploit the potential of systems thinking and turbocharge the prospects of not only ICBs but place leadership over the coming years.

Systems leadership principles

Our approach is based on some simple but important principles which provide the blueprint for success. These include:

• Understanding the basics – Do systems truly understand each other? We may get to know the names and faces around the table, but do we know the organisations, the sectors, the regulators, the politics…? Our experience suggests that many systems don’t know the basics about their partners. We think it’s a good place to start.

• The importance of context – Systems exist in volatile and uncertain environments, and it is within this context that success or failure is defined. Is there a shared recognition of the political, economic, societal and technological context, both now and into the future? How will this affect decision-making at operational and strategic levels? How might context affect people, resources or community sentiment? Success happens within and because of the context of our operations, not despite it. If we want successful places, we need to understand the context they create.

• Influencing – The intricate threads of systems are bound together by a delicate balance of interests, concerns, accountabilities and egos. The traditional power of hierarchies is blunted when progress requires coalitions rather than orders. Influence is a critical component of effective systems leadership and leaders need to understand how to unleash its potential.

• Embracing complexity – “We need a period of stability to make progress”. How many times has that refrain been heard around the board or managerial meeting tables? What if there isn’t a ‘period of stability’ for the foreseeable future? What if, rather than wishing away the complexity that defines the political environment in which we operate, we learned to embrace it?

• Adaptive leadership – To lead in complexity, leaders must learn to adapt. Adaptive leaders see the world as it is, not how they wish it were. They learn to be pragmatic, alert to changes and opportunities, brave, principled and see risk as a fixture rather than a threat. Systems are complex. Places are complex. Effective system leaders make that complexity a strength rather than a weakness.

• The power of narrative – Places are bound by stories. Their histories, successes, failures, opportunities and challenges are all expressed in narrative terms that in turn link to human stories. Leaders need to embrace the power of narrative as a means of both mobilisation and establishing trust and credibility. History is littered with the power of narrative – both progressive and malign – because stories change things and systems leaders harness the power they provide.

Systems leadership is not a short-term policy initiative. It will be a prerequisite of successful places – despite rather than because of the whims of central government policy-makers.

We welcome the focus on systems that ICBs have created, but we have been around long enough to know that further reorganisation is a matter of when, rather than if. No matter; systems leadership will remain very relevant to the prospects of service users whatever comes next, and the very best systems will have the very best leaderships.

Questions for integrated care boards and system partners

• To what extent have you been able to accelerate your development by drawing on best practices from other sectors?
• Have you developed an agreed vision for your integrated care system?
• How are you changing the way you engage with stakeholders and manage communication?
• To what extent are you building dispersed system leadership skills?
• To what extent are you applying systems thinking to reallocate resources, redesign services and influence policy?