We're all leaders: integration means collaboration

Integrated working sits at the heart of plans to transform health and social care services. It is increasingly seen as critical to both delivering more efficient, higher quality and patient focused care.

‘Integrated care can only develop if people have the support to work differently’

In practice, this can range from formal multiagency teams, to coordinated networks, to full blown organisational mergers.

However, simply putting teams together or restructuring organisations across the divide does not lead to integrated care, as the recent King’s Fund report Clinical and Service Integration: the Route to Improved Outcomes demonstrates.

• Roundtable: How to make integration happen effectively
• Integration supplement: Patients first must be the focal point

True integration

Whatever form it takes, at its core, integrated care can only develop if people have the support to work differently. In other words, if integrated services are to deliver integrated care they must be supported by a collaborative culture in which professionals come together around the patient, and are not confined by the needs of their organisation or their professional world.

So, why does something that makes so much sense and sounds so simple prove difficult in practice? There are challenges to integrated working at a range of levels:

Context - how will organisations be appropriately resourced, paid, regulated, incentivised and organised when care is not bound by organisational structures?

• Logistics - how will information be shared and processes united to allow people to operate collaboratively?
• Human - how will organisations and individuals manage the new ways of working required to be effective?

Reviews of integrated working highlight a range of enabling factors. In particular:

• shared budgets, or at least aligned financial and performance incentives;
• common protocols and processes;
• access to a shared record; and
• IT that supports effective communication.

These factors make it easy for people to work together and to understand the full picture of the individual in front of them.

However, equal attention must be paid to the third area: human factors. Collaborative working means changing ways of operating, culture, and even, in some cases, people and organisations’ sense of professional identity and authority.

There are also the personal feelings that arise when we feel our authority is threatened, our role changed or we are required to work with a whole new “tribe”. How often do you hear: “If only they would… then we could do our job”, often about other internal departments, never mind external organisations?

And, underpinning it all, integrated care can lead to changes, consolidation or rationalisation of roles, increasing the personal risks of collaborative working. At heart, integrated care will be achieved through changing culture, not through processes alone.

‘If only they would… then we could do our job’

Challenging as it may be, integrated services and the collaborative working that underpins them are not new concepts for the public sector. They have been implemented in different forms - for example, through local strategic partnerships or the Every Child Matters agenda in local government.

The health and care sector approaches this therefore, not with a fresh piece of paper, but a wealth of learning on which to reflect. We draw here on some of our experience and research from working with local authorities and their partners.

Integrating services

In a complex, system focused service, the traditional top-down management structures that dominate the sector are increasingly unviable. Organisations will need to focus on empowering teams to manage and solve issues on the front line.

To some degree we are already seeing self-managed or “empowered” teams in the clinical commissioning group context with their flat ownership structures and focus on clinical enablement.

Mike Holmes, associate medical director of Hull CCG, highlighted this in his December HSJ article, in which he explored how concepts of self-managed teams (and beyond) are supporting system transformation in Hull.

But how does this work? In an organisation which has self-managing teams instead of a formal organisational structure, empowered workers operate within much wider organisational spaces.

‘Leadership roles therefore become increasingly focused on enabling’

These shared spaces focus on the importance of teamwork, multiple skills, cross-functional processes, shared learning, continuous improvement and self-organisation. Self-managing teams are able to engage with complex and problematic situations and solve them systemically without pushing things upwards.

This is not simply a “free for all”. Clear boundaries and processes, good data and communications and team focused reward frameworks support frontline teams to manage themselves and their work more actively and with greater responsiveness to the needs of their “customers”.

These teams require strong trust between professionals and clear skills in ways of working, such as critical thinking, root causes analysis, emotional intelligence and conflict resolution.

Leadership roles therefore become increasingly focused on enabling - from establishing how individuals and teams can operate and measure their impact, to creating the broader context within which they can be successful and work collaboratively. This alone leads to a flatter structure as more traditional management tasks, such as resourcing and managing performance, are given to the team.

Networked professionals

While professionals may be operating within empowered teams, it is more likely they will be working across a range of virtual teams. We call this new mode of operating “networked professionals”, with individuals on the front line increasingly practising informal leadership.

This ranges from consultants who work with GP colleagues to coordinate care to the case worker who coordinates a care plan. But what do networked professionals look like and what supports them to be effective? Our research in this area of the education sector helps us think about how to operate this informal leadership successfully. We looked at people who built effective and broad networks that allowed them to influence without formal authority and work together effectively.

They demonstrated a number of features against their “averagely” connected control group. They were:

• outcomes focused - the end results mattered more than process;
• client serving - they organised themselves and their relationships around the beneficiary;
• plain spoken - they avoided jargon and professional distinctions;
• intolerant of boundaries - they asked “why not?”;
• team oriented - they worked in groups rather than alone;
• accountable - they accepted responsibility and scrutiny; and
• trusting and trustworthy - they understood the importance of trust where they lacked formal authority to influence, and built and used it carefully.

While technical expertise will remain at the core of professionalism, those developing integrated care will also need to develop skills and behaviours that support collaborative working.

Working towards integrated care

Another area of distinct comparability is children’s services. Our research found that success came from a change process that had a clear and concrete purpose and built momentum and trust carefully as it progressed.

This highlighted these steps:

• Sense of purpose and understanding - Successful collaborations spend time agreeing a shared starting point, understanding each others’ worlds, and establishing clear outcomes around a clear sense of purpose.
• Go one step at a time - Many partnership initiatives fail when they move too fast, as they take on risky activity before trust and commitment are in place.
• Enable people to work together - The practicalities are important. Effective collaborative working is supported by strong, neutral project management and chairing of partnership groups. This means aligning wherever possible with existing ways of working to support others to engage.
• Communicate - Given their time again, nine out of 10 partnership leads say they would communicate more. If integrated working (both as a way of working and as a specific redesign of services) is a culture change process as much as a service reconfiguration process, then communication is critical - both to ensure focus on outcomes (why do we keep doing this when it is hard), commitment (what results we are able to achieve) and engagement.

Embedding the collaborative culture that sits at the heart of effective integrated care takes time, energy and passion. However, it provides a huge opportunity not only to improve patient’s experience of care, but also to empower practitioners to lead.

Kate Wilson is an associate director at Hay Group