Systems, collaboration, power: realising the benefits of the ICS framework

To mark the establishment of integrated care systems (ICSs) as statutory bodies on 1 July 2022, we have been exploring the leadership implications of this fundamental shift in a series of masterclasses.

These sessions were organised with Cindy Cox and Toby Lindsay of the King’s Fund and examined collaborative practice and modes of partnership working. Also, under discussion were the mindsets and behaviours required to achieve the recalibration of competition and autonomy to a more interdependent and place-based approach. The challenges and messy realities of such large-scale change were recognised, in particular dealing with ambiguity and uncertainty at a time when much of our workforce felt overwhelmed and exhausted.

Below we distil the key practical insights from these sessions:

• Map out the system visually. Lay out what you know about the overall territory and the components within it. Illustrate how it is constructed, what holds it together, and how the elements interact. This helps acknowledge and contain the anxiety of not being able to fully see or understand the system as a whole and can help identify what is common and different between certain components.

• Consider what behaviours help or hinder collaboration. Relationship building, clarity of purpose, and acknowledgement and management of power dynamics are key to successful collaborations. In addition, collaborations that survive and thrive are reflective spaces where learning is ongoing and participation is enabled for all; it’s essential to create the time and space for learning, even when pressure and change make it difficult.
• Recognise that partnerships need ongoing attention. The development and progression of relationships happen through conversation, and this is how we can unlock the full potential of a partnership and catch any unhelpful patterns before they become entrenched. As per Kantor’s model of communication, it is valuable to take the role of ‘bystander’ to observe how a group or partnership is working. Then, by reflecting and building forward, we can improve the effectiveness of the partnership by having more fruitful conversations more often. As Foucault said: “Discourse transmits and produces power, it reinforces it, but also undermines and exposes it.”

• Power needs particular attention. Power can be an emotive word, in part because we tend to think of having ‘power over’ others and that if you have power over me I have less power. Yet power can be understood as a generative and infinite resource. Martin Luther King’s words remind us that “Power, properly understood, is the ability to achieve the purpose.” The recognition of power differences and the management of them is essential. Without it, those who feel disaffected and disempowered often disengage, but we can only utilise our collective power in the present moment, together. Therefore, working with pre-existing and emerging power dynamics in partnerships is central to achieving the ambition and desired outcomes for the people they serve.

• Strive for true collaboration as a place of connection. All of our work rests on the foundation of mutual trust between partnership members, which we can build through taking risks and showing our vulnerability to each other. Over the course of the masterclasses, a process was designed to encourage ever-deepening connections, by allowing risk-taking and empowering vulnerability in practice. In our partnerships we should aim for a place where all parties have a voice, power is generative, and learning is ongoing. This ‘relational’ work can feel like a distraction from ‘real’ work and is particularly difficult in times of change, uncertainty and pressure. Yet connection and trust are the enablers that allow partnerships to achieve task and purpose.

• Use purpose as both fuels and focus for change. Discomfort in partnerships is inevitable if we are stretching ourselves to be our best for the people we serve. All of us must consider the changes and developments we may need to make to achieve a mindset and way of being that allows for true systems leadership to emerge.

We were delighted and inspired by the work participants did over the course of the masterclasses. As statutory ICSs advance, with all their complexity, it is vital that personal transitions and interpersonal reorientation are given time and attention. Developing the skills and practices of systems leadership and learning together will be fundamental in shaping impactful partnerships and, ultimately, realising the full potential of ICSs to improve public health.