Enhancing health in care homes: system leadership in action

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Part of Embedding enhanced health care in care homes

This quote came to mind when we reflected on the outcomes of our first King’s Fund/My Home Life Care homes, health, housing and social care learning network – a network established to improve collaborative working between many of the organisations involved in improving the health of older people living in care homes.

‘System leadership’ was not a topic on the network’s agenda, nor was this phrase mentioned by participants, even though skilled system leadership is required to drive the close co-ordination between care homes and other organisations – in health, social care and housing – needed to enhance the health of care home residents.

The leadership demonstrated by participants in the network was not ‘top of the tree super’ leadership (which we have advocated a move away from for years) nor ‘across a whole sustainability and transformation partnership’ leadership, but it was system leadership: collaborative, cross-organisational, non-hierarchical leadership orchestrated by a ‘coalition of the willing’. Network participants saw this approach as the only way to ‘get the job done’; the job in this case being to advance the enhanced health in care homes agenda.

It was interesting to observe that participants, particularly care home managers, while certainly self-identifying as leaders of their care home, were unlikely to recognise themselves or their activities as displaying ‘system leadership’. Perhaps we shouldn’t be surprised at this; Nicholas Timmins has reported similar findings. People ‘doing’ system leadership often don’t recognise it as such, and even if they do, would never refer to it in that way for risk of negatively impacting carefully crafted relationships based on equity and mutuality.

This managing of cross-system relationships is important. Care home managers, for example, reported previous experiences of ‘status’ issues associated with the work they do – looking after frail older people who are, for some, ‘out of sight, out of mind’, until they are deemed to cause a health-related ‘problem’. Care home staff have reported the experience of being seen as ‘less’ than their more acute care-orientated clinical sector counterparts and have spoken of a system that often tells them what to do, does ‘to’ them and generally undervalues them despite their considerable contribution. This less-than-helpful approach militates against integration, is a far cry from the behaviours of effective system leaders and does little to support relationship building. Notably, none of the participants in our network reported experiencing this: whatever their background, participants understood the contribution and importance of the care home sector, although many of the areas were at the foothills of partnership-working on shared agendas.

Members of the groups shared complementary strengths, knowledge and a relational approach to getting things done and instigating practice change – all characteristics of system leadership – to plan positive system change. This included bridging old fracture lines (eg, public sector/independent sector, acute sector/community sector) and working with different funding lines; competing interests, agendas and priorities; perverse incentives; mixed professional identities; and the never-ending turnover of staff.

Our experiences during the network meetings led us to reflect on how to share the learning from the network – and other areas in England – more widely. To do this we spoke to network participants and others working on enhanced health in care homes to understand the lessons they were learning from their experiences. Their views form the basis of our report, Enhanced health in care homes, which looks at real-life experience from 15 areas. The key issue these areas focus on is removing inequalities of access to health care for care home residents as part of the broader move towards more integrated health and care. Learning networks might be one small practical step towards the implementation of this complex agenda.

With gratitude to Professor Julienne Meyer (My Home Life) for her many insightful comments.

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