Developing programme theories of leadership for integrated health and social care teams and systems: a realist synthesis

Background: As the organisation of health and social care in England moves rapidly towards greater

integration, the resulting systems and teams will require distinctive leadership. However, little is known

about how the effective leadership of these teams and systems can be supported and improved. In

particular, there is relatively little understanding of how effective leadership across integrated care

teams and systems may be enacted, the contexts in which this might take place and the subsequent

implications this has on integrated care.

Objective: This realist review developed and refined programme theories of leadership of integrated

health and social care teams and systems, exploring what works, for whom and in what circumstances.

Design: The review utilised a realist synthesis approach, informed by the Realist And Meta-narrative

Evidence Syntheses: Evolving Standards (RAMESES) publication standards, to explore existing literature

on the leadership of integrated care teams and systems, complemented by ongoing stakeholder

consultation. Empirical evidence specifically addressing leadership of integrated teams or services was

limited, with only 36 papers included in the review. The evidence collected from these 36 papers was

synthesised to identify and build a comprehensive description of the mechanisms of leadership of

integrated teams and systems and their associated contexts and outcomes. Consultation with key

stakeholders with a range of expertise throughout the process ensured that the review remained

grounded in the reality of health and social care delivery and addressed practice and policy challenges.

Results: Evidence was identified for seven potentially important components of leadership in

integrated care teams and systems. These were ‘inspiring intent to work together’, ‘creating the

conditions to work together’, ‘balancing multiple perspectives’, ‘working with power’, ‘taking a wider

view’, ‘a commitment to learning and development’ and ‘clarifying complexity’. No empirical evidence

was found for an eighth mechanism, ‘fostering resilience’, although stakeholders felt that this was

potentially an important, long-term component of leadership. A key message of the review was that

empirical research often focused on the importance of who the leader of an integrated team or service

was (i.e. their personality traits and characteristics) rather than what they did (i.e. the specific role that

they played in integrated working), although stakeholders considered that a focus on leader personality

was not sufficient. Other key messages highlighted the way in which power and influence are used

by integrated service leaders and identified the hierarchies between health and social care which

complicate the leading of integrated teams and systems.