There is a lot of talk in and around the NHS about system leadership. In this post, I’ll summarise the prevailing view of what this kind of leadership comprises before adding some perspectives of my own.
What is system leadership?
The World Economic Forum’s 2019 paper on systems leadership highlights two recurring features in accounts of systems leadership. First, its core elements: system insight (particularly an appreciation of complexity); a capacity to build and mobilise coalitions; and a collaborative and empowering style of leadership. Second, the interdependencies between these elements.
Another useful source is The Dawn of System Leadership by leading management thinkers, Peter Senge, Hal Hamilton and John Kania (2015).
The authors describe three core capabilities of system leaders:
- the ability to see the larger system
- fostering reflection and more generative conversations
- shifting the collective focus from reactive problem solving to co-creating the future.
Senge et al also describe three ‘gateways to becoming a system leader’:
- ‘re-directing attention: seeing that problems “out there” are “in here” also—and how the two are connected
- ‘re-orienting strategy: creating the space for change and enabling collective intelligence and wisdom to emerge
- ‘practice, practice, practice: all learning is doing, but the doing needed is inherently developmental’.
These are credible lists of the attributes of system leaders. However, by their nature they are detached from the specific context in which leadership takes place. Context is very important.
Power and autonomy
One key variable is the formal authority vested in the leader. System leaders will both have power themselves and the ability to generate more through the way they lead and collaborate. While possessing their own authority means system leaders bring something to the table, it is easy for those areas of focused power and responsibility to crowd out the messy business of building shared purpose and coalitions of change.
This, for example, is why many local authority leaders end up relegating the collaborative task of place shaping behind the direct responsibilities of service provision. Just the other day I facilitated an away day for lead officers and councillors in a big city where the participants had to keep reminding each other that they were civic leaders, not just service deliverers.
A second, related, variable is the degree of autonomy a system leader has as part of a larger system. The issue here is less absolute freedom – all leadership deals with constraints – but the level of unpredictable interference. If system leaders have continually to respond to top-down imperatives, it damages their efficacy and the credibility of the partnerships they are trying to develop.
Leading health systems
With these thoughts in mind, and focusing also on the specific challenges in integrated care systems, there may be other leadership qualities we will need to see.
First, leaders need to develop with their partners a compelling account of the specific and concrete value they believe system working can bring. The capacity of candidates to articulate a mobilising and credible value-adding proposition should be a key criterion guiding the appointment of ISC chairs and chief executives.
According to NHS England and NHS Improvement (NHSEI) guidance, ICSs will be required to develop an ‘integrated care strategy’ for its whole population using best available evidence and data, covering health and social care….and addressing the wider determinants of health and wellbeing.’ The guidance goes on to say that, ‘We expect these plans to be focused on improving health and care outcomes, reducing inequalities and addressing the consequences of the pandemic for communities.’
To make real its stated intentions about devolution and local responsiveness, it is important that NHSEI signals its desire to see every strategy show distinctiveness, innovation and evidence of local engagement
There is a recurrent problem when central government asks local bodies to write strategies; they have tendency to end up ticking boxes and – despite huge differences between places – producing depressingly similar ambition and plans. Local economic strategies produced by local enterprise partnerships in 2019 and 2020 were similar not just for this reason, but because a high proportion were written by the same team of consultants!
The tone and content of the Integrated Care Partnership (ICP) engagement document published a few days ago by the Department of Health and Social Care and NHSEI is encouraging. But the fact – relayed to me by a number of frustrated leaders – that currently many ICS meetings seem primarily to comprise PowerPoint presentations about progress towards national targets does not bode well.
To make real its stated intentions about devolution and local responsiveness, it is important that NHSEI signals its desire to see every strategy show distinctiveness, innovation and evidence of local engagement. This would not only be about challenges and ambitions but the way the ICSs will work. In some cases, ICSs want to make a big difference themselves, while in others (for reasons of history, geography and politics) they will be more of a facilitator supporting place-based action.
Think like a system, act like an entrepreneur
Second, leaders need to develop a ‘split screen’ mind set. I have spent many years thinking about leadership and change, looking particularly at why so much policy and strategy (including many initiatives I have helped develop) fail to meet their stated goals. Two types of problem stand out.
ICS leaders must combine thinking ambitiously and holistically with a capacity for agility, responsiveness and opportunism
Often, interventions are too narrow, seeking to change one or two variables in a complex, interconnected system. Feedback loops then mean those interventions generate unexpected and sometimes perverse outcomes. Also, interventions can suffer from various forms of path dependency. Long developed plans are implemented, but when things don’t work out as expected, policymakers double down, intensifying a failing process rather than responding to reality. Providing questionable evidence that the plan is working comes to be more important than genuinely assessing whether it is. My former colleague in Downing Street, Geoff Mulgan, memorably referred to the journey from ‘evidence-based policymaking’ to ‘policy-based evidence making’.
In my previous role at the RSA, we developed a toolkit to support leaders in response to these recurrent patterns. We advocated ‘thinking like a system but acting like an entrepreneur’. Given the inevitability of unpredictable events – including central and regulatory interventions – ICS leaders must combine thinking ambitiously and holistically with a capacity for agility, responsiveness and opportunism.
Right now, there is much concern that the onerous and pressing governance preparations required for ICSs will distract from a focus on real-world impact. But getting the ethos of governance right is important. Just before the pandemic I led a session with senior civil servants which culminated in me asking them what most got in the way, and what most enhanced, their capacity to think like a system and act like an entrepreneur. The two questions received the same answer: ‘process’. Where it is needlessly bureaucratic, hierarchical, not focused on outcomes, not properly facilitated, process saps morale and dissipates energy. Conversely, when processes are egalitarian, outcome-focused and properly facilitated, they can be transformative.
The challenge to the centre
Which takes me to my final point. The partners in ICSs are tasked with focusing on improving population health outcomes. This must mean expanding the focus of health policy from what the NHS does to the wider determinants of health, which lie in areas ranging from housing and welfare to planning and transport.
In a strong and wide-ranging speech last week, Sajid Javid announced a rebranding of the Office for Health Promotion as the Office for Health Improvement and Disparities (‘disparities’ seems to be the Conservative-approved way of referring to ‘inequalities’). The Secretary of State said that one of the Office’s core goals is: “to work with partners right across government and beyond to act on the wider factors that contribute to people’s health outcomes. Because we know our health depends on so many factors: your job, your house, your environment, your education and so much more. It has to be a truly cross-government approach”.
This is, of course, absolutely right, but it will take lot more than the good intentions of new arm’s-length body to achieve genuine buy in across Whitehall and the Cabinet to improving population health. There is little sense right now that ministers and officials in departments other than DHSC feel this is their business. It is, for example, vital that health is at the centre the much-awaited Levelling Up white paper.
We are all going to have to do a lot of learning if the new health system is to fulfil its potential. Wouldn’t it be powerful if DHSC and NHSEI accepted openly that system leadership is as much a challenge for them and the centre as it is going to be for ICSs and places? Instead of change being mandated it could be co-learning process in which the centre and local systems support each other on the journey to transformational change in the nation’s health. After all, ‘you must do what we say’ isn’t nearly as powerful as ‘join us in what we are all trying to do’.
Matthew Taylor is chief executive of the NHS Confederation. Follow him and the organisation on Twitter @FRSAMatthew @nhsconfed