Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by integration correspondent, Sharon Brennan.

HSJ has reported on several stories in the last few weeks about top tier sustainability and transformation partnership and integrated care system leaders stepping down.

The biggest of these departures is Jon Rouse from Greater Manchester. On the same day his resignation was announced, so was Louise Patten’s, who is leaving her role as joint leader of Buckinghamshire and Oxfordshire CCGs. Though not an STP or ICS leader, she played a big role in the old Bucks ICS and now expanded ICS in the Thames Valley. These were followed this week by the news the Hertfordshire and West Essex STP is seeking its fifth leader in four years.

These stories indicate how hard it is to find, and then retain, good leaders capable of taking on the challenges of bringing together organisations.

A new Nick Timmins King’s Fund report finds that, while there is a concerted push to get the whole of England to meet the national April 2021 deadline to become an ICS, there has been less focus on what happens beyond that date.

Mr Timmins talked to 16 STP/ICS leaders and found that, while heading up these systems is a challenge that experienced leaders are prepared to step up to, there is little consistent planning to develop a pipeline of new leaders to replace those who will inevitably choose to retire or move on at some point.

His work showed that — as The Integrator has previously observed — many of the current system leadership roles are currently taken by people at the end of their careers, who feel they have less to lose in terms of career progression. Combined with that is the concern that people who have only worked within the silos of providers or commissioners, rather than across both, may not have the breadth of experience needed to gain the confidence of an STP/ICS board.

Just as importantly, there is still a dearth of BME leadership at the top levels of STPs/ICS. HSJ analysis in the summer revealed just one system chair or executive lead was from a BME background. Owen Williams, Calderdale and Huddersfield Foundation Trust chief executive, said at the King’s Fund’s annual conference this week: “It’s damn right we need to have a conversation about [BME] leaders at ICS level… it does matter.” He cited the fact that ethnic minorities consistently have worse health outcomes as just one reason why it’s important ICS boards reflect the diversity of the population they serve.

The issue of where these leaders are to come from is exacerbated by the fact ICS roles are not ones which are attracting 40-something aspirant chief executives. As Philippa Slinger, the lead in Devon, puts it: “There’s no legal entity, there’s no job security, there’s not even a clarity of cross-party government policy.”

Some of these issues may be eased through the legislation proposed by NHS England and supported by the Conservatives — but if and when this might come into effect is uncertain, as is whether it would really solve the problem.

Some systems, such as Surrey Heartlands and Dorset, are investing in system leadership and development to help generate their own local pipeline, but these two regions are already recognised as exemplary ICS. Where will the more challenged systems find their recruits?

NHS England and NHS Improvement need to start thinking now of what happens past 2021, as they manage their senior leadership talent. Leadership programmes should adapt quickly to ensure those coming through are diverse both in experience and in gender/ethnicity to ensure they can cope with system challenges. When the old guard leaves it is not clear who will be able — let alone willing — to step up.