The job of leadership in integration is to enable stakeholders to work together and share responsibilities, risks and successes when they are used to working separately with independent budgets and outcomes. Evidence shows that this type of leadership needs to be present at all levels of the healthcare system.
At the organisational level, executive level support is necessary for multi-agency working, but this must be followed by the release of resources to support it. At the team level, there must be a willingness to work together and share patients, information and knowledge. At the individual level, every healthcare professional providing integrated care must be an advocate for the new service, proactively identifying gaps and demanding the best care from themselves and others, whilst working towards the same outcomes.
Generating commitment to a share purpose
The leadership style thought to be most likely to successfully deliver large-scale change like service transformation, is one that generates commitment to a shared purpose through collaboration. Specifically, leadership that is shared, distributed and flexible seems to be most effective. But what strategies should leadership adopt for integration? Two leadership strategies are described in the literature.
The development of communities of practice
A community of practice is defined as a group of people with a common sense of purpose who agree to work together to share information, build knowledge, develop expertise and solve problems. The use of connected mini-transformations to generate wider system transformation Mini-transformations enable wider transformation through a series of smaller changes which are easier for stakeholders to engage with.
Building a diabetes community of practice
Consultants are expected to provide clinical leadership in both their medical practice and in managing and improving services. I have significant experience in providing clinical leadership in the context of integrating services by working with healthcare professionals from different disciplines and different organisations. Integration has often proved a challenging task because healthcare professionals are driven by a range of values and priorities depending on the organisation they work in. From my perspective, the challenges are to resist taking a dominant position to progress changes quickly and ‘sort things out’, and more broadly to continue to develop and deliver change when there is continual upheaval and shifting priorities within the healthcare system.
In Oxfordshire, what helped us achieve change was building a community of practice, and going out to the community with an open agenda and an understanding of our own limitations. The acknowledgement that each part of the healthcare system is interdependent is very powerful and can lead to building trust across organisations. We continued to share knowledge and information, but we were also learning about what was working for patients and healthcare professionals, and what was not, for example:
· What is the best use of specialist time?
· How are patients selected for discussion at multidisciplinary team (MDT) meetings?
· How are discussions at MDTs guided and who should lead them?
· Who should take responsibility for the actions?
Indeed, it became apparent that effective leadership was more about facilitating corporate learning than it was about making decisions. Our success in Oxfordshire has been that we have managed to cut through perceived hierarchy and bureaucracy whilst working together, and learning with and from each other about what does and does not work. Personally, I believe we have managed to develop a feeling of ‘being in it together’. When it comes to developing organisational frameworks around primary and specialist care cooperation, this solidarity will bring increased confidence that the framework will be a success.
Leading mini-transformations
Mini-transformations, or incremental change, means introducing many small, gradual changes to a project instead of a few large, rapid changes. Our experience of introducing integrated diabetes care in Oxfordshire initially began as a push towards transforming the whole service, which was to be achieved in under a year. The leadership teams across the stakeholder organisations were generally supportive, but there was insufficient resource allocated, in terms of staff, time, and financial resource, to enable this to happen.
We communicated with all GP localities across Oxfordshire to try and build engagement. During three years of work to develop the programme, we came across a number of barriers (which included business plans not being accepted) which delayed the service transformation. Fortunately our engagement attempts saw some success and we identified some general practices that were interested in proceeding with limited integration, even though we could not proceed with the whole service. In order to address the burning problems of working within a fragmented service, and to demonstrate the benefits of the new approach, we continued with our work to provide specialist input within primary care settings, albeit with a pilot on a much smaller scale.
Sharing leadership of care with patients
This is an area that is increasingly becoming recognised in terms of both patients’ own care, and across the wider population. Healthcare professionals and commissioners may feel uncomfortable talking about the power of patients to drive changes in healthcare systems. However patient involvement will become increasingly important as commissioners and providers take difficult decisions regarding service development. Nowadays, we more easily acknowledge that an individual patient can direct their care, or co-lead with the support of a healthcare professional. However, we rarely think about patient leadership at a more strategic level, and how to encourage and enable patients to be involved. If patients are well-informed about what to expect from a diabetes service, and feel empowered to speak for themselves, they can drive not only their own care, but that of the whole population in question.