What does it take to lead in an integrated system?

system leader

This new report from the Kings Fund was launched at their 5th Annual Leadership and Management Summit on 20th May.  The report  builds on earlier publications from the King’s Fund (which can be found on their web site), further exploring system leadership.  The author interviewed 10 senior leaders; the findings demonstrate the challenges of leading change and transformation, in particular emphasising key skills and behaviours.

Why so important?

System leadership, as a concept, is attracting more interest within the health service and is seen as particularly relevant as we move towards more integrated and person-centred models of designing and delivering care, through programmes and initiatives such as the Better Care Fund, the Five Year Forward View Vanguards and DevoManc. The complexity and uncertainty of health systems, especially in the current climate of financial pressures, is seen as requiring a more collaborative style of leadership, where influence and persuasion of agendas rather than direct control is needed.


The subtitle of the report takes its name from a comment from one of the interviewees, that system leaders need to learn to be “comfortable with chaos”


The report is based on 10 interviews with senior leaders in health and social care. Timmins reports the leaders were selected for their experience in working across boundaries to influence and deliver change.  The interviewees are from different contexts – it could be argued that the inclusion of interviewees from other parts of the public sector may have offered more diverse perspectives and I was surprised to see only one local authority participant. However, the report does add to the growing literature on system leadership in health.

behind the scenes

Much of the work of a system leader may be “behind the scenes” as opposed to being seen as leading from the front

Key findings

There are a number of lessons shared by the interviewees, which will resonate at different levels of health and social care.  The key points include:

  • System leadership is not easy, typically involving “wicked problems”, and involves many trade-offs.
  • The role of system leader calls for a paradoxical combination of consistency and flexibility – one of the interviewees references the need to maintain objectives but adjust the methodology as needed.
  • It takes time to achieve results which isn’t easy given demands to demonstrate results.
  • A number of interviewees highlight the importance of starting with a “coalition of the willing” advising other leaders to build a strong and diverse network to understand the system from a range of perspectives (clinical, patient/carer, commissioner, provider etc).
  • Stability is critical to sustaining momentum and turnover of key staff have set change programmes back considerably.
  • More support is needed to develop system leaders in their roles as enablers and catalysts.
  • System leaders need to build an evidence base for change which resonates locally and must be willing to co-design change and to “give away ownership”.
  • The current system isn’t set up to facilitate change, often encouraging competition rather than collaboration.
  • A number of barriers exist within the current system (such as differing performance and regulation mechanisms; fragmented assurance processes; lack of clarity on roles and responsibilities).

There is a recognition that the job of a system leader is not easy – leaders will need to develop their own approaches to develop personal resilience.

The shared experience of the interviewees is consistent with other key literature on system leadership.  Whilst the report may not necessarily offer brand new theoretical insights, it does bring some practical experience of the reality of being a system leader.


System leadership requires a different set of skills and behaviours to the command and control style of leadership.  Emotional intelligence is referred to frequently by interviewees, particularly, the ability to influence and persuade; active listening; and empathy.  The building of relationships and trust is essential to progress, and this requires a significant investment of time and energy. One of the interviewees likens system leadership to a rollercoaster, noting the need to be “comfortable with chaos”.

The experience of the interviewees suggests that perfect planning does not automatically lead to effective implementation and indeed, it is here where significant challenges lie. In particular, commissioners will need to consider: how joint investment will work in reality; how to enable staff to work across boundaries; and how benefits from change will be shared across the system.


There is a tension in understanding that change takes time to embed but at the same time, being under significant pressure to deliver quickly

Key considerations for commissioners

Integrated care and system change will need system leadership at all levels – some key considerations for commissioners include:

  • How are staff and stakeholders supported to adopt new ways of working
  • How are new leaders, throughout the system, supported to develop the skills to become system leaders?
  • Where are the key relationships which need investment?
  • What support networks do I have internally and externally?
  • How do I reflect individually and how do we reflect collectively?
  • How do we build in resilience (personal, organisational and system) to this change?


Timmins, N (2015) The practice of system leadership: being comfortable with chaos, King’s Fund.

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