Health and social care organisations providing services for older people are undergoing considerable change in the ways in which services are operating. These changes are being shaped by a range of different factors, including rises in the proportion of older people in the population, increasingly strong arguments for making services more effective, and moves towards the integration of services to avoid gaps and overlap. In this world, many have identified a need for organisations to have strong leadership, and to develop new visions and creative ways of delivering them.
However, many of the discussions and ideas about leadership are based on old ideas about leaders as dynamic, decisive, authoritarian and competitive. Although this model of leadership may have been appropriate in a world where services were in competition with each other for funding or for clients, in a world where the emphasis is on integration and working collaboratively, it has increasingly become irrelevant and unhelpful. It can fail to address the many challenges of leadership in integrated care, where loyalties may be tested as organisations find themselves collaborating and competing at the same time.
This chapter examines the different models of leadership more suited to working in integrated care. First, it discusses the difference between old and newer ideas and then it identifies what characteristics are needed for leadership in integrated care, and the systems needed to support it.
Of the many different definitions of leadership, the one adopted here is ‘the articulation and effective communication of a viable vision’ (Strange and Mumford 2002). This definition has two components:
The objectives and intended outcomes of leadership can be explained in terms of the two components of the above definition.
In developing integrated care, this vision may be radically different from previous ideas about how an organisation should go forward. If organisations have developed in an environment based on notions of competition, where there were few incentives to look at the whole system, then a vision that moves towards collaboration and integrated working will seem a difficult one to achieve. Leaders must therefore spend time working out the ‘viability’ of their vision – working out how it can be achieved, and what will help or hinder progress.
This definition encompasses the activities that a leader will take on to learn about and analyse the organisation and the challenges it faces, and the role that they have – to set direction, make decisions and motivate colleagues. Leadership in integrated care will involve all of these activities and roles, but will take place in a multi-agency context, where the analysis will encompass all relevant organisations, and the direction setting and decision-making will be done collaboratively.
The second element of the definition involves the relationship between the leader and the rest of their organisation. Articulating and communicating the vision effectively requires leaders to understand the language, concerns and perspectives of their colleagues. Their communication has to be carried out in a compelling way, to persuade people to work towards the same organisational goal, which may be particularly difficult if it is a radical departure from past practices.
The elements of visioning and articulating are distinctive aspects of the leadership role, which distinguish it from the management role. While the leadership role involves setting agendas and goals, the primary management role is to develop strategies for implementation (Caldwell 2003). This does not mean that managers cannot be creative and innovatory, but leaders are more likely to take on the broader agenda-setting responsibilities.
Ideas about leadership have changed over the years as the contexts of leadership and the values and goals of societies have changed. Early historical examples of leaders have tended to be autocratic rulers who led their subjects to great military victories or economic successes. They displayed great conviction and determination during conflict with enemies, and enjoyed the unquestioning obedience of their loyal subjects.
So these leadership models are founded on the ideas of conflict and rule, with little attention paid to ideas of co-operation or democracy. As societies have become more complex – particularly with industrialisation and the growth of business – some traces of the military model are still evident, as organisations see themselves as fighting to win, and look for leaders who appear decisive and decided.
‘Old’ models were of the autocratic leader who would – through personal qualities alone – drive through change, with some more sophisticated models suggesting that situational factors could play a part. It was a question of the right person being in the right place at the right time, rather than simply a matter of finding the right person.
In an overview of theories of leadership, Horner (1997) identified a number of different approaches. One of the earliest approaches to defining leadership was to focus on the personal attributes of leaders. This was based on the idea that leaders were born, not made, but no clear traits emerged. Following this effort, another approach was tried, focusing on leaders’ behaviour. Again, however, no clear characteristics were identified, partly because the research did not pay attention to context: successful behaviour depended on the leader’s situation.
Contingency theories, which looked at traits, actions and contexts, were more sophisticated and served to make the complexity of leadership more apparent. In particular, one sort of leadership theory included the characteristics of those who were led – the followers. Eventually, these contingency theories led to attempts to develop decision-making tools that stated what leaders should do in different circumstances (Horner 1997).
Broader theories of leadership have focused on organisational culture and the management of change. Successful leaders understand the culture of the organisation and its change processes can set a strategic direction, communicating this direction and defining the vision and values of the organisation. Still more theories identify the ability to motivate staff, influence behaviour and set goals as key aspects of leadership.
More recent thinking has extended this to a more inclusive model of leadership that takes a ‘whole-system’ approach, looking at the way in which the system supports, sustains and responds to leadership. This has led to models of leadership in which the direction and motivation of the system is based not only on the individual qualities of the leader, but also on how they enable the whole system to be supportive of innovation.
New models focus on organic leadership, which involves nurturing and growing rather than dictating. One of these is post-modernism. Post-modern ideas embrace ambiguity and challenge the idea that there is one right way to do things, so post-modern models of leadership question old ideas of leadership as having a simple cause-and-effect process.
New models of leadership have moved away from the ‘heroic individual’ idea to look at relationships and networks, and also to look at ‘followership’ – in other words, the way in which everyone in a system or organisation works together, towards a shared and mutually owned goal. These ideas are moving towards the idea of leadership as a team activity rather than the domain of one individual (Caldwell 2003).
The notion of collaboration extends within and across organisations. Instead of leaders thinking of their own organisation only in terms of its being in competition with others, whole-systems thinking and leadership places emphasis on effective leadership, which involves promoting the collaboration of organisations across the system, for the benefit of clients.
More recently, we have seen the development of theories of transformational leadership. These focus on definitions of leadership as involving creativity and personal development for the leaders and others. Some of this thinking is found in discussions on ‘learning organisations’, as an aid to effective working.
A ‘learning organisation’ is one in which there is a capacity to respond to changing contexts, which the organisational analysts Shelton and Darling (2003) argue cannot be done if an organisation relies on ‘the traditional mechanistic organisational paradigm’. These more recent ideas are of special relevance to leadership in integrated service development. Rather than assuming a competitive environment, they are more able to address issues of integration and collaboration, and in the emphasis on personal growth for all, they encompass issues of staff development and user involvement.
This reflects the argument (Wilderom 1991) that leadership in service provision organisations differs from that in industrial organisations, largely because in service organisations it involves direct interaction with service users to set goals and strategies. So leadership in service organisations is more complex, and requires sophisticated negotiation and consultation skills. Fig 9 shows one framework for leadership qualities that has been developed by the National Health Service in the UK.
Fig 9 was designed specifically to highlight the challenges for leadership in the process of modernisation – moving from the old structures to integrated services. The model suggests that effective leadership involves setting direction (involving a number of different activities and skills) and paying attention to the details and practicalities of delivering the service.
Included in the list of qualities necessary for delivering the service is ‘collaborative working’, which is particularly relevant to integrated care. Also included are the skills of ‘leading change through people’ and ‘empowering others’, which again suggest a different approach to leadership, away from the ‘heroic’ individual model. This comes close to the ‘empowering leadership’ type identified by Pearce et al (2003), which involves the inclusion and development of everyone in a system or organisation, as opposed to the ‘directive leadership type’, which is more about giving instructions and commands.
If we put together the characteristics of integrated care for older people discussed in this resource book, and then relate those to the features of leadership discussed above, we can identify the characteristics required for leadership in integrated care. These characteristics include an awareness and understanding of the complexity of integrated care, and the perspectives of all of the different stakeholders involved. In integrated care, the stakeholders include a range of staff with very different professional, educational and organisational backgrounds, and older people and their families, who will have different needs, preferences and experiences, as well as representatives of ‘the system’, such as government commissioners, inspectors and insurers.
In this complex world, then, leadership in integrated care services can raise many issues and problems. Each organisation in the system has its own history and goals, including meeting financial targets, legal responsibilities, and policy directives, so balancing these tensions requires a sound understanding of these issues, and the ability to develop strategies to meet these competing demands. This means that leadership to develop integrated services for older people requires the characteristics summarised in the box below:
Leadership in integrated care needs to:
Moving from old models of leadership to new ones involves change in the organisation’s systems. While autocratic, combative leaders may have been supported by systems that maintained authority and discouraged challenge and debate, new leaders will need different systems. These are systems that will support good leaders, but they are also systems that good leaders should develop for the people that they work with.
To develop leadership for integrated care in an organisation, it is vital to promote or develop systems to support it. These include systems that:
Each of these factors is discussed in detail below.
Strange and Mumford (2002) argue that vision comes either from a leader’s personal values and standards (ideological vision) or from their understanding of social needs and change requirements (charismatic vision). The complexities of developing integrated care services suggest that both types of vision are needed, incorporating the ideological goals of developing a collaborative system in response to an understanding of the social context.
Implementing and managing integrated care involves responding to the growing understanding of the complexities of older people’s needs by adopting a set of values that advocate collaborative and open working. As the understanding of older people and the social contexts in which they live grows, integrated care is ever more strongly supported as a way of delivering effective services that will meet their needs.
However, it does requires a set of ground rules or ethical codes on working collaboratively that need clear guidelines on working in an open and honest way, with a clear framework for ‘fair play’. This would include organisations not actively engaging in activities that may damage each other, and identifying and discussing any potential conflicts.
All staff should have leadership responsibilities at all levels, and need to be able to work across organisational boundaries. This should not mean, however, that accountability for overall direction is shared uniformly. Within organisations, there are differences in power, responsibility and rewards, and these must be reflected in the expectations placed on different members of the organisation.
Staff need support and training in how to work collaboratively and in groups, but for this to happen there needs to be an atmosphere of honesty and trust. There are a number of different models of leadership education available (for an overview, see Moulton 2004). This involves clarifying accountability and enabling opportunities to learn from failure, and may need a willingness to relinquish power and control over some activities in order to develop the bigger picture.
There may be difficult balances to strike between the needs of service users and staff – these may be different or conflict. The effect on the service user should be the touchstone for development, and care must be taken to ensure that this has priority.
Attention must also be paid to ‘followership’ – the skills, abilities and needs of others in the organisation – and how it can be supported. Being able to follow effectively requires skills and abilities, but these are often dismissed or not acknowledged – everybody focuses on the leaders. The ability to put strategies into operation requires a grasp of basic principles, and some commitment to them, but good followership is different to uncritical obedience. As principles are put into practice, many difficulties or anomalies may arise, and followers need to be able to think critically about change, rather than just following orders.
Specialised courses in leadership are being developed and are increasingly available. They typically include strategic planning, service mapping, visioning, motivation and communication. However, they tend to be less didactic than traditional courses, and seek to build on experience and skills, often encouraging sharing of knowledge among leaders. Programmes such as this can actively foster the ethos of collaboration rather than competition, and so may promote integrated working.
The traditional approaches to evaluating leadership mainly focused on setting performance targets and then measuring whether they were attained. Monitoring integrated services leadership, on the other hand, is more difficult because the interest is also in processes rather than only outcomes – and the outcomes are more complex.
An example might be a hospital that works alongside a day care centre to ensure that all their respective inputs are consistent. Evaluating both organisations’ records to make sure that they meet the needs of both organisations, and those of the clients, is more difficult than just measuring whether they meet the needs of one organisation. The evaluation might also need to include an assessment of the negotiation that led to the design and content of the records – whether everyone was consulted, and how effective these processes were. In integrated care, much depends on external factors and the action of other services, so the measure of the leader is in how effectively and creatively they respond to them.
Alternatively, measures of leadership can include:
These two options are explained below:
Ensuring the continued development of leadership for integrated care depends not only on the policies and systems promoting it, but also the absence of those that discourage it. These can include:
These factors are outlined below.
There are a number of policy developments that have promoted the development of new leadership. These include:
The issues involved in promoting effective leadership for integrated care are related to those discussed in chapters 9 and 11. These developments require leadership that is inclusive, culturally intelligent, and aware of the differences between collaboration and competition. This form of leadership is necessary to manage integrated services through potential difficulties in early stages, and also to build robust relationships that can respond effectively to future change.
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