Developing programme theories of leadership for integrated health and social care teams and systems: a realist synthesis

Abstract

Background As the organisation of health and social care in England moves rapidly towards greater integration, the resulting systems and teams will require distinctive leadership. However, little is known about how the effective leadership of these teams and systems can be supported and improved. In particular, there is relatively little understanding of how effective leadership across integrated care teams and systems may be enacted, the contexts in which this might take place and the subsequent implications this has on integrated care. Objective This realist review developed and refined programme theories of leadership of integrated health and social care teams and systems, exploring what works, for whom and in what circumstances. Design The review utilised a realist synthesis approach, informed by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards, to explore existing literature on the leadership of integrated care teams and systems, complemented by ongoing stakeholder consultation. Empirical evidence specifically addressing leadership of integrated teams or services was limited, with only 36 papers included in the review. The evidence collected from these 36 papers was synthesised to identify and build a comprehensive description of the mechanisms of leadership of integrated teams and systems and their associated contexts and outcomes. Consultation with key stakeholders with a range of expertise throughout the process ensured that the review remained grounded in the reality of health and social care delivery and addressed practice and policy challenges. Results Evidence was identified for seven potentially important components of leadership in integrated care teams and systems. These were ‘inspiring intent to work together’, ‘creating the conditions to work together’, ‘balancing multiple perspectives’, ‘working with power’, ‘taking a wider view’, ‘a commitment to learning and development’ and ‘clarifying complexity’. No empirical evidence was found for an eighth mechanism, ‘fostering resilience’, although stakeholders felt that this was potentially an important, long-term component of leadership. A key message of the review was that empirical research often focused on the importance of who the leader of an integrated team or service was (i.e. their personality traits and characteristics) rather than what they did (i.e. the specific role that they played in integrated working), although stakeholders considered that a focus on leader personality was not sufficient. Other key messages highlighted the way in which power and influence are used by integrated service leaders and identified the hierarchies between health and social care which complicate the leading of integrated teams and systems. Limitations Evidence specifically addressing leadership of integrated care teams and systems was limited and lacking in detail, which restricted the degree to which definitive conclusions could be drawn around what works, for whom and in what circumstances. Conclusions Research into the leadership of integrated care teams and systems is limited and underdeveloped, with ideas often reverting to existing framings of leadership in which teams and organisations are less complex. In making explicit some of the assumptions about how leaders lead integrated care teams and systems this review has contributed significant new perspectives, offering fresh theoretical grounding that can be built on, developed and tested further. Future work By making explicit some of the assumptions underlying the leadership of integrated care teams and systems, this review has generated new perspectives that can be built on, developed and tested further. Study registration This study is registered as PROSPERO CRD42018119291. Funding This project was funded by the National Institute for Health Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 7. See the NIHR Journals Library website for further project information.

Barriers and enablers of integrated care in the UK: a rapid evidence review of review articles and grey literature 2018–2022

“…The subtheme of evaluation methods acted as a key barrier to integrated care; seven review articles found insufficient evidence of evaluation due to heterogeneity within social enterprises, contexts within which they operated and the wide variety of health impacts ( 28 , 34 , 43 , 47 , 49 , 51 , 52 ), as described:…”

“…The need for this to be managed, or at least kept at bay, by clarity of message from those in positions of authority is another natural response to uncertainty. The difficulty with which this is genuinely provided by leadership, who are expected to recognize these hidden, embedded complexities and offer communication that is both clear and mindful of this is, therefore, considerable [( 51 ), p. 65].…”

“…Other authors noted the lack of support from a strong evidence base for the roles of leaders and the development of leadership skills and training ( 38 ) and that there should be a focus on improving outcomes for their populations through “strengthening local leaders’ ability to have greater and more flexible decision making in primary and social care, supported through a more joined up national policy approach” [( 68 ), p. 64]. Furthermore, leadership in integrated care appeared to be compromised by prior professional hierarchies, tensions, unconscious biases, and political motivations existing within healthcare and social care teams ( 51 ).…”

Integrated care system leadership: a rapid realist review

“…This involves continuous learning and fostering an adaptive learning culture (Charles et al, 2018;Hendry et al, 2021 Working Together Integrated care leadership involves tackling complex 'wicked' problems and managing conflicts (Hulks et al, 2017;Social Care Institute for Excellence, 2018). Leaders must collaborate, share power, and use distributed leadership approaches (Aunger, Millar, Rafferty, Mannion, et al, 2022;Baylis and Trimble, 2018;Harris et al, 2022;Miller and Stein, 2020). Clear governance structures and data sharing are crucial for managing risk and decision-making (Booth-Smith, 2017;Cheng and Catallo, 2019;Harris et al, 2022).…”

“…Trust fosters collaboration and understanding of partners' motivations (Deffenbaugh, 2018;Ham, 2022;Harris et al, 2022).…”