Integrated Care System Leadership: A Realist Evaluation


  • Lisa Knight Liverpool John Moores University


  1. Introduction

Health and social care services in England have moved towards a system of partnership working known as Integrated Care Systems (ICSs) consisting of all NHS Provider Trusts, Primary Care Services including GP Practices, Local Authorities, Care Providers, and Voluntary, Community and Social Enterprise organisations involved in the provision of health and social care. As complex systems covering large geographical areas, ICSs are led by senior leaders to improve population health, reduce health inequities, and enhance value for money. Given their recent formation, little is known about their leadership. Available sources are either dated within the academic literature or are described in the grey literature with little reference to theoretical or empirical foundations. This research is intended to contribute to the gap in theoretical and practical knowledge by developing a framework to explain effective leadership in ICSs.

  1. Aim, Research Questions, and Objectives

2.1       Aim

To evaluate leadership in Cheshire & Merseyside ICS and provide a framework on effective leadership in ICSs.

2.2       Research Question(s)

How does ICSs leadership work, for whom, and in what circumstances?

  1. What are the activities and behaviour of leadership utilised by senior leaders within an ICS?
  2. Which contextual factors influence these activities and behaviours?
  3. Which Context-Mechanisms-Outcomes (CMO) configurations explain leadership within an ICS?

2.3       Objectives

  • To identify senior leaders' leadership activities and behaviours in an ICS.
  • To identify the contextual factors that influence the activities and behaviours leaders utilise within an ICS.
  • To utilise context (C), mechanisms (M) and outcome (O) chains to explain what works (outcome), how (mechanisms) and under what conditions (context).
  • To develop a framework that explains effective leadership in ICSs
  • To provide recommendations for practice that support effective leadership of ICSs.
  1. Justification & Literature Review

Within both the academic and grey literature there is a general agreement that leadership and leadership approaches are critical factors in the ability of organisations to implement, develop, and sustain integrated care; however, despite the whole-scale implementation of this approach to health and social care commissioning and delivery across England limited empirical studies have been conducted. Research in the wider field has focused on the skills, qualities, and abilities of leaders rather than the action and behaviour of leadership, tending to consider who a leader is rather than what they do (Sims et al., 2021, p.13), which limits the ability of ICSs to understand and utilise leadership practices that respond to the complex needs of partnership working across systems. Successful integration requires a combination of strong leadership and governance from senior leaders at the system level across health and social care (Asthana et al., 2020). Furthermore, research examining the functioning of integrated health systems has identified leadership ability as a key factor (Bhat et al., 2022). It has also been suggested that an ICS's operation and sustainability are significantly influenced by a leader's ability to move from an organisation-centred leadership style to one that focuses on leading across multiple organisations (Charles et al., 2018). However, there appears to be an implicit assumption within the literature that senior leaders can apply their existing leadership approach to the newly formed structures and governance of ICSs with limited guidance underpinning the actions or function of leadership styles.

  1. Theoretical Foundation

Phase 1 (Realist Review) of this study will draw on theories of collective and systems leadership, the results of a realist review, and primary data collection to develop initial theories of effective leadership in ICSs; these will be refined and tested in Phase 2 (Realist Evaluation). The complexity of ICSs alongside an identified lack of theoretical foundations for understanding their leadership, supports the adoption of a realist evaluation (Greenhalgh et al., 2009). Furthermore, given the emerging nature of ICSs,  a realist evaluation can go further than asking ‘does it work’ by asking ‘what works, how, in which conditions and for whom’ (Pawson and Tilley, 1997, p.210). Realist research is underpinned by a critical realist ontology; one that takes the position that there is a ‘real’ world that is independent of our experience or interpretation of it. Epistemologically, this research takes a position that focuses on causal explanations which assumes underlying causal processes, termed mechanisms, can have multiple outcomes and that different contexts can precipitate different actions or events. It is concerned with developing and testing 'programme theories'; multiple causal chains describing the context, mechanisms, and outcomes of a particular phenomenon, in this case, leadership within an ICS.

  1. Research Design

A case study strategy has been selected as it aligns with a realist approach to research and is ‘particularly suited to research questions which require a detailed understanding of the social or organisational processes because of the rich data collected in context’ (Hartley, 2004, p.323). In line with a theory-driven realist approach a multi-method qualitative approach to data collection has been adopted to allow for the richness of contexts and mechanisms to be examined; programme theories will be tested and refined through non-participant observations, document analysis of strategic publications, and interviews with key stakeholders within the ICS.

  1. Initial Theories of Effective ICS Leadership (Phase 1 Findings)

    Table 1: Initial theories of effective ICS leadership utilising Doing Things Differently: Rethinking Leadership Behaviours as an organising framework for theories (NHS North West Leadership Academy, 2021).



Effective Integrated Care System leaders hold themselves and others to account for improving outcomes for the local population. They utilise available intelligence to take actions that support targeting and prioritisation of local communities. Effective Integrated Care System leaders support and encourage learning, curiosity, and calculated risk-taking enabling innovative approaches that lead to service improvements.


Effective Integrated Care System Leaders communicate a clear vision, fostering a sense of purpose across the system regarding the achievement of agreed Integrated Care System outcomes.

Leading & Visioning

Effective Integrated Care System leaders have a clear vision that promotes a sense of mutual accountability, providing opportunities for others to develop, make decisions, and take ownership of problem solving through the engagement of all partners in the reduction of health and social care inequalities

Relating & Communicating

Effective Integrated Care System leaders build relationships at all levels of the system, they promote partnership and collaboration. Leaders encourage a collective agreement about what needs to be achieved and communicate openly about how and why decisions are made


  1. Relevance & Contribution

This study will provide valuable information to those who work within such systems to help them understand and support leadership development more effectively. Furthermore, this study is expected to contribute to closing the gap in the academic literature regarding the leadership of ICSs by using a novel approach to leadership evaluation; in doing so it will make explicit the underlying causal processes and influencing contexts that shape leadership in ICSs, providing a clear and accessible framework to explain effective leadership practice.


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