System leadership: reflections on learning by doing

Governance and relationships

Much attention is being paid to governance arrangements as integrated care systems (ICSs) prepare to become statutory bodies in April 2022. Equally important, if not more so, is to invest in relationship building. In a seminal article on system leadership, Peter Senge and colleagues wrote:

"Transforming systems is ultimately about transforming relationships among people who shape those systems. Many otherwise well-intentioned change efforts fail because their leaders are unable or unwilling to embrace this simple truth."

Transforming relationships requires sustained effort by many people recognising that changing complex systems takes time. It is analogous to cultivating a garden on a large scale - best done by a team in which each member knows his or her role and follows an agreed plan. Different parts of the garden will require attention at different times, with every member of the team sharing responsibility for its growth and development.

Things that have worked well

From the outset of the pandemic, our three acute hospitals worked together to expand intensive care capacity and support each other when admissions peaked.

One of the great strengths of partnership working in Coventry and Warwickshire is the close and positive relationship between NHS organisations and local authorities. Coventry City Council and Warwickshire County Council share a commitment to improving the health and wellbeing of citizens and work closely with one another. Joint meetings of the two health and wellbeing boards, known as the Place Forum, which is aligned with the health and care partnership board, lead this work.

Another strength has been the use of mutual aid in the response to COVID-19. From the outset of the pandemic, our three acute hospitals worked together to expand intensive care capacity and support each other when admissions peaked. They also supported neighbouring systems in the Midlands and further afield, particularly in the early weeks of 2021 when a surge of cases placed extreme pressure on intensive care.

Mutual aid has continued in work to tackle the backlog of demand for elective care created by the pandemic. Coventry and Warwickshire is one of the accelerator sites for elective recovery and has made a promising start in reducing the number of people waiting for tests and treatments. This includes using private hospitals under contract to the NHS, as well as arranging extra sessions in NHS hospitals and drawing on best practice from Getting It Right First Time programme and other sources.

Delivery of the vaccination programme was a notable example of collaboration in action during the pandemic. Primary care networks played a major part in the programme alongside NHS partners, local authorities, volunteers, the army and others. The knowledge that general practices had of their patients and local authorities of their communities was an invaluable asset.

The four places in Coventry and Warwickshire are where most of our ambitions are being delivered. Partnerships in each are growing in confidence, both in work to improve health and wellbeing and to join up health and care. Each place has developed its own governance arrangements involving a range of partners, including district and borough councils.

Things that have been challenging

Progress also depends on leaders being willing to compromise, even when this may not be in the best interests of their organisations.

Not everything has worked well and we face challenges in tackling several wicked issues. These challenges encompass delivering overdue improvements in the care of people with learning disabilities and autism, working to reduce a substantial underlying financial deficit, and improving specialist services where we know greater integration would deliver better care.

Progress on many of these issues requires leaders to embrace a system mindset and be willing to think and act differently. Behaviours that served organisations well when competition was the animating force in the NHS have been found wanting and long-standing perceptions of the intentions of partners have been an obstacle. In some cases, progress has been stymied by stark differences in leadership styles.

Progress also depends on leaders being willing to compromise, even when this may not be in the best interests of their organisations. A positive example of this was collaboration on finances: CCGs provided additional funding to two trusts at the end of 2019/20 to maximize the benefits to the system of provider sustainability funds. Reaching agreement on other issues has been more difficult, in part because altruistic behaviour is still a work in progress.

It is a truism that progress occurs at the speed of trust and that trust develops through repeated interactions among leaders who make credible commitments that they keep. Leaders must exhibit integrity in everything they do, be respectful in their dealings with peers, and be willing to listen with an open mind to the views of others. Efforts to build trust are easily and rapidly undermined when there is a disconnect between what leaders say and what they do.

The solution to many of these challenges lies in leaders taking time out with skilled facilitation when appropriate. This has been difficult during COVID-19 because of workload pressures and often the impossibility of meeting in person. As Senge and colleagues remind us, leaders themselves must be committed to transforming relationships if systems are to work effectively.

Where next?

As I come to the end of my term as an ICS chair, I am encouraged by the progress made and only too aware of what remains to be done. The journey will be more successful if system leaders are capable of learning by doing and willing to borrow from others who may be further ahead. At a personal level, they must also be comfortable with the often chaotic world in which systems arise from the ashes of the old NHS.

I often think that being a system leader is analogous to playing snakes and ladders, where progress towards the goal can be set back by chance events. System leadership is of course much more serious and consequential than a board game, but the feeling of moving forward and then falling back is real. Success will come to those who build a guiding coalition by winning hearts and minds and securing alignment behind a shared vision.

Chris Ham is chair of the Coventry and Warwickshire ICS. You can follow Chris on Twitter @profchrisham