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The revolution will be improvised
How new approaches to leadership are driving integration

Debbie Sorkin reports on how systems leadership projects around the country are bringing together care providers, commissioners and service users in order to integrate services.

If you’re a provider of social care services, and you are in receipt of funding from a local authority, then whether you work with older people, people with learning disabilities, people with physical disabilities or people with mental health issues, you’re likely to have had battles over funding in recent years. In its latest Budget Survey Report 2014, the Association of Directors of Adult Social Services estimated that since 2010, local authority adult social care departments have had to make savings of 26 per cent in their budgets – the equivalent of £3.53 billion over the last four years.

Aside from leading to a radical reduction in the number of people eligible for local authority care funding – the National Audit Office estimated in its Adult Social Care in England: Overview in March 2014 that 87 per cent of the adult population lived in local authorities that only provided care services to those with substantial needs or higher. The last four years have also seen fee levels for providers being significantly cut back, in some cases to the extent that providers have walked away from local authority contracts.

The funding cuts have coincided with a much greater emphasis on service integration and redesign: integrated services, based around the person using care and support, are at the heart of the Care Act, and the evidence for integrated services providing better outcomes for people has been clear from recent studies including the European Observatory’s Policy Study, What is the evidence on the economic impacts of integrated care?.

But there are major structural, cultural and financial barriers to integrating social care and health. Financial incentives and funding mechanisms are different. Healthcare is free at the point of delivery, and costs for acute care are calculated on a tariff, or episode, basis. Social care is not free and for local authorities, is effectively means-tested. Many providers will have first-hand experience of the structural divides that make them feel they are often on the outside looking in as far as decision-making around integration is concerned, even though it is the independent sector that is best-placed, through local knowledge and sector expertise, to ease the pressures on the acute hospitals in their area.

There are a number of ways in which health and social care have been piloting new ways of working, to bring services together for the benefit of service users and to support more efficient, and effective, use of resources.

Systems leadership 

One of these ways has been through using systems leadership approaches.

Systems leadership describes the kind of leadership you use when you’re seeking to lead across organisational boundaries – so when you go beyond your own service or organisation and interact with others, often with very different priorities and points of view.

It describes the way you need to work when you face large, complex, difficult and seemingly intractable problems where you need to juggle multiple uncertainties, where no person or organisation can find or organise the solution on their own, where everyone is grappling with how to make resources meet demand which is outstripping them, and where the way forward therefore lies in involving as many people’s energies, ideas, talents and expertise as possible.

It recognises that leadership isn’t vested in people simply because of their title or position; that it is possible – indeed, necessary – for leadership to be shared and ceded, and that you can come together on the basis of a shared ambition, and accept partial or clumsy solutions on the way to getting there. Working with uncertainty, and ambiguity, is a given, and it’s expected that people will experiment with different methods and processes as a result.

Systems leadership is, therefore, particularly useful when you’re looking to integrate services, and to redesign them around the person, at a time when you have less money than you need and more expectations than you can cope with. In other words, it’s leadership for our times.

Alongside identifying a research base, a group of national organisations – spanning social care, health care and public health – have put a new initiative in place to try systems leadership approaches in practice. This initiative, which is already involving social care providers, is called Systems Leadership – Local Vision.

Systems Leadership – Local Vision is currently funding 25 projects around the country. The aim of these projects – each of which looks to create change in a difficult or ‘breakthrough’ issue across a locality – is to develop systems leadership at local level, to create new ways of working in support of delivering integrated services, and to achieve measurable improvements in health, care and wellbeing. Progress on an issue needs to involve a number of different sectors. The projects commit to applying what they learn about systems leadership to other issues, and to sharing that learning so that other areas can benefit.

Systems leadership in action

The current projects cover a broad range of issues. In Kent, social care providers have come together with the local authority and NHS Trusts to develop new approaches to integrated commissioning, with large-scale ‘open space’ events bringing providers, commissioners, service users and carers together to shape what future services should look like.

In the London Borough of Merton, they have created a pilot approach to integrated health and social care for people with two or more serious long-term conditions, putting service users at the centre and building up strong links with service users, carers and the voluntary sector. Birmingham has used a community asset-based approach, working with the independent and voluntary sectors to identify how localities across the city – ‘healthy villages’ – can support people and ease the demand on public services.

Across Dorset, Bournemouth and Poole, senior figures from across health and social care have come together to develop a coherent local system to deliver integrated health and social care, pooling budgets and working with a range of delivery partners.

Other projects have covered broader issues around long-term health and wellbeing. In Cornwall and on The Wirral, systems leadership programmes have looked at how to alleviate the rise in food poverty (use of food banks in Birkenhead, for example, had increased by 47 per cent over four months in 2013-14, from 9,000 to over 13,000). Outcomes have included more local markets and food networks, building better systems between local farmers and local consumers, so there is more use of surplus food and less waste; more community cafes; and a development of skills-based food curriculum for schools.

Finally, in Plymouth, representatives from health, public health, the local council, the voluntary and third sectors, the police and the local university have been working together on reducing late-night street drinking in order to benefit health, reduce demands on A&E and reduce ‘streetscene’ costs: the systems leadership programme has led to joint decisions on where funding should best be invested to achieve better outcomes.

The revolution will be improvised

Initial findings from the projects have been published in a recent report, The Revolution will be Improvised. Although the projects have proceeded at different speeds, and some have made stronger progress than others, there is emerging evidence of providers being involved earlier in discussions around integration, and becoming centrally involved, rather than being consulted late in the day or not at all. There are also encouraging signs of real co-production and co-design with service users and carers. Where the projects are working, even if there isn’t an immediate payoff, relationships between commissioners, providers and others involved have improved to the extent that they are in a much better position to have difficult conversations – for example, around funding – than they previously were.

What are the lessons about what makes collaboration a success? A number of key messages have emerged repeatedly:

  • Service users, not organisations and services, must be at the centre. This is constantly claimed and rarely delivered, but when it happens, the results are transformational.
  • Systems need to recognise that co-producing services with users is hard. It is a different way of working and needs skills and strategy to make it happen.
  • Leaders need to see themselves as part of the collective leadership of the system, as well as leaders in their own services and organisations.
  • Collaborative skills are now essential to success. Organisations should make the ability to collaborate a key requirement for employment, development and promotion at every level.
  • Key abilities include being able to operate in networks without clear rules; instinctively making connections; building shared values and trust; and building coalitions of support.
  • Getting things done depends on relationships, trust and commitment, not formal structures.
  • Organisations and staff need to think and act strategically: the squeeze on resources makes long-term thinking imperative. The greater the pressures, the more important strategic thinking becomes.

Increasingly, providers are finding themselves in a position where they need to work alongside others such as the local authority, Clinical Commissioning Group, Health and Wellbeing Boards. In these circumstances systems leadership may be the key to enabling everyone to work together to achieve the best outcomes.

Further reading

Systems Leadership – Exceptional leadership for exceptional times

The Revolution will be Improvised

More information about systems leadership and the systems leadership programmes, can be found at www.localleadership.gov.uk

Details of how to apply for funding for new Systems Leadership – Local Vision
projects can be found at www.localleadership.gov.uk/place/lvinvitation/

Debbie Sorkin is National Director of Systems Leadership at the Leadership Centre.
Email: debbie.
Sorkin@localleadership.gov.uk

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