Delivering integrated services successfully, with a firm focus on measurable outcomes and overcoming barriers that may have been in place for many years, demands skilled and creative leadership and a consistent, values-driven culture.
Leaders engaged through this programme shared an acknowledgement that they need to articulate a coherent and authentic narrative for their teams that enables them to see how their own organisations will develop and enhance the service it delivers within the wider system. Leaders have found that the current formalisation of place-based working presents opportunities to respond more effectively to the demands facing health and care systems. They consistently drew out that authentic, collaborative, and inclusive leadership is key to creating the culture and environment that support teams’ space to innovate and improve.
Leadership alignment and shared ambition
All systems involved in this programme cited leadership as an essential part of successful integration at place. Where organisations come together in new ways, different cultures, with different historical contexts and expectations, meet.
Insight from the sites contributing to this work made clear that providing an environment in which these cultures can come together in a spirit of positive collaboration to facilitate the development of new shared cultures of partnership working, required highly skilled authentic leadership.
A common thread to successful integrated working is alignment on a shared ambition. Consider the following:
- Is there a clear narrative? Does everyone understand what integrated working at place will look like and what it will achieve for people?
- Can all leaders in the system articulate the narrative and ambition coherently?
- Will all leaders be supported to afford priority to the change as being equal to the ambitions of their own organisation?
- Is the identity or brand of the integrated agenda at place strong enough to transcend organisational barriers?
- Does the leadership group have a shared set of aspirations and action plans around equality and diversity, informed by an understanding of the experiences of staff from minority backgrounds?
HARNESSING the DIFFERENT CULTURES
Studies have identified a tendency for different organisations within a system or place to exhibit markedly different cultures. Differences are seen between the varied approaches the NHS and local authorities take to change, performance, management, and delivery.
Ideally, this diversity of cultural norms can be harnessed to bring together wider views and approaches resulting in stronger, even more positive solutions. However, the range of norms can, in practice, generate disagreement and friction.
Leadership across the system from different organisations and particularly at place, must have absolute alignment and clarity on the direction and outcomes, so that differences in culture and approach can then exert a positive impact on the overall work.
What is the reality? The challenges being felt by local systems
Systems involved in this programme reflected that while skilled leadership and establishing and maintaining the right culture are perhaps the most important aspects of successful integration at place, they also presented the greatest challenge. Reasons for this include:
- Developing successful partnerships can require substantial time commitment from senior leaders, in addition to their existing leadership responsibilities within their organisation.
- Many leaders have developed and succeeded in a culture which was more conducive to competitive behaviour. The challenge for them now is to unlearn these skills, ways of working and thinking, even though they have served them well in the past.
- Communication can be a challenge across partners. This can result in trust taking longer to build and grow, particularly between health and social care, where different emphases will play out.
- Relatively few leaders have professional experience working in all the different areas of the health and care system. A lack of familiarity with differing sectoral cultures can lead to unintended consequences during change programmes.
- Leaders are managing the pressures and incentives of their individual organisations, which may at times exist in tension with the broader needs of the partnership agenda.
- Partnership working demands a different style of leadership, based on understanding, inclusion, negotiation, discussion, and persuasion. Hierarchy, command, and control may sit well in some individual organisations but will not create successful partnerships. This means that leaders must be able to adapt and develop their leadership styles to be successful in integrating services.
Shared learnings on practical tools and approaches
The following learnings have been drawn together based on the engagement and input into this programme of work.
- Establish a core group of leaders, ideally small in number, who share common ambitions, can build trust between each other and between organisations, and make decisions. Embedding independent challenge to the group, or at set points, is vital.
- Take ownership for elements of delivery as a group – working through practical challenges to make delivery happen together will build stronger relationships than conversation and discussion alone.
- Invest in relevant skills development for leaders, either individually or as a team of place-based leaders. Creating space for this leadership organisational development work can give space to build trusting relationships and strengthen the guiding coalition.
- Hold strong and clear to the overall vision and outcomes targeted, tracing activity back to this regularly.
- As leaders in the guiding coalition, take the commitment to the partnership back into individual organisations and ensure mechanisms are in place to share and drive the partnership outcomes with teams.
- Ensure that organisations’ boards have engaged with the vision and outcomes targeted at place, and that the guiding coalition are in ongoing dialogue with organisations’ boards to ensure constructive challenge is embedded into the programme.
- Leaders should ‘seek first to understand’. The assumption should be that other colleagues are coming from a positive place. The leader’s role is to understand why they hold the perspective they do.
- Seek feedback from other system partners and operational teams - and take action from it. Consider setting aside time to step back and reflect on progress so far, share successes, honest concerns, and constructive feedback to partners or between individuals.
- Support leaders in the guiding coalition to engage with data and insight, and regularly interrogate whether the programme is delivering the envisaged benefits and adapt if not.
- Celebrate success and encourage teams when the right behaviours are seen.
- Prioritise time to do this well and spend time with frontline teams to talk about the success and what it has meant for outcomes.
We hope that this publication will not be the end of the programme, but the beginning of a conversation. A series of events will be available to attend to explore the themes in greater detail and share experiences.
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