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System leadership: Lessons and learning from AQuA's Integrated Care Discovery Communities


  • David Fillingham Image

    David Fillingham CBE

  • Belinda Weir photo

    Belinda Weir

A consensus is emerging in England around the concept of ‘integrated care’ as the best hope for a sustainable NHS. For leaders in the health care system, this represents an immense challenge. Leading across complex interdependent systems of care is a new and different role, undertaken alongside the already difficult task of leading successful institutions.

This paper seeks to identify the skills, knowledge and behaviours required of new system leaders and to learn from systems attempting to combine strong organisational leadership with collaborative system-level leadership approaches. The paper draws on three years' development work with leaders in health care systems in north-west England, undertaken by the Advancing Quality Alliance (AQuA) and The King's Fund which has adopted a 'discovery' approach to developing integrated care and the leadership capabilities supporting it.

Key findings

  • Delivering system-level integration will require a combination of a collaborative approach to leadership, with leaders at many levels in the system, and directive, effective organisational leaders.

  • The experience of the AQuA Integrated Care Discovery Communities shows that both of these different leadership approaches can and ideally should be modelled within the system, but this is challenging at an individual level.

  • Health and social care organisations are complex adaptive systems. Successful approaches to developing system leaders recognise this and the need for a new leadership approach, although paradigms of ‘command and control’ leadership are prevalent.

  • Studies show that the world’s most successful health care systems make widespread and systematic use of improvement methods. These encourage learning by doing, using small tests of change to observe, reflect and explore what works best for a particular context.

  • Experience from the Discovery Communities suggests a new style of leadership only begins to develop where there is widespread readiness for change.

Policy implications

  • We currently under-invest in developing system leaders, although there are emerging examples of how to do this well. If there is a genuine desire to develop integrated approaches, this must be accompanied by an increase in the scale and pace at which leaders are developed at every level of the system.

  • There is a startling lack of impact measures in current attempts to develop system-wide leadership. A formative evaluation framework is vital to give signals of what is and isn’t working, as well as tracking progress towards improved outcomes for patients, staff and taxpayers.