Extended abstract submitted for the Faculty of Business and Law Research Day 2022

Knight, Lisa

English

BLResearchDay (LJMU)

Faculty Research Day  8th December 2022    1    A Realist Evaluation of ICS Leadership  Lisa Knight Faculty of Business and Law, Liverpool John Moores University l.knight@ljmu.ac.uk  1. Introduction Health and social care services in England are moving towards a system of partnership working. These partnerships will plan and deliver services on a regional basis through governance structures known as Integrated Care Systems (ICSs). After Legislative proposals for the formal establishment of ICSs they became legal entities, with statutory powers to commission and provide health and social care services, in July 2022. They consist of all NHS Provider Trusts (Hospital, Community, and Mental Health Trusts), Primary Care Services including GP Practices, Local Authorities, Care Providers, and Voluntary, Community and Social Enterprise organisations that are involved in the provision of health and social care. As complex systems covering large geographical areas, ICSs are led by senior leaders, working within the system's structures, 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.  2. 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? a) What are the activities and behaviour of leadership utilised by senior leaders within an ICS? b) Which contextual factors influence these activities and behaviours? c) 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.  3. Justification 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 no empirical studies have been conducted. Grey literature and policy documents demonstrate an implicit assumption that leadership practices are transferable from one health and social care setting to another. Furthermore, 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 Faculty Research Day  8th December 2022    2    limits the ability of ICSs to understand and utilise leadership practices that respond to the complex needs of partnership working across systems.  4. Literature Review Successful integration requires a combination of strong leadership and governance from senior leaders at the system level across health and social care (Ham et al., 2011; González-Ortiz et al., 2018; 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). Moreover, it has 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; Deffenbaugh, 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.   5. Theoretical Foundation The initial stages of this study will draw on theories of collective and systems leadership, the results of a realist review, and initial data collection to develop an initial causal explanation of how leadership in ICSs is expected to work; considering contexts, underlying causal processes (mechanisms), and patterns of outcomes associated with that leadership which will be refined and tested throughout the study. 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 assess real-time changes and corresponding impacts (Jagosh et al., 2022), going 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 (Westhorp et al., 2011). 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.  6. 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). A theory-driven realist approach aims to test, refine, and retest programme theories. Accordingly, a multi-method qualitative approach to data collection has been adopted to allow for the richness of contexts and mechanisms to be examined. In line with the research approach, programme theories will be tested and refined through non-participant observations, document analysis of strategic publications, and interviews with key stakeholders within the ICS. Sampling in realist approaches considers the contribution each document, observation, or interview can make to the testing and refining of theory; as such, the participants, observations, and document research within this study are not the units of analysis but rather ‘a collection of micro events and processes’ that can be examined in multiple ways to test CMO chains and programme theories (Manzano, 2016, p.348).  7. 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. Faculty Research Day  8th December 2022    3     References Asthana, S., Gradinger, F., Elston, J., Martin, S. and Byng, R., (2020) Capturing the Role of Context in Complex System Change: An Application of the Canadian Context and Capabilities for Integrating Care (CCIC) Framework to an Integrated Care Organisation in the UK. International Journal of Integrated Care, 201, p.4. Bhat, K., Easwarathasan, R., Jacob, M., Poole, W., Sapaetharan, V., Sidhu, M. and Thomas, A., (2022) Identifying and understanding the factors that influence the functioning of integrated healthcare systems in the NHS: a systematic literature review. BMJ Open, [online] 124. Available at: https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2021-049296. Charles, A., Wenzel, L., Kershaw, M., Ham, C. and Walsh, N., (2018) A year of integrated care systems: reviewing the journey so far. The Kings Fund. Deffenbaugh, J., (2018) Becoming an integrated (accountable) care system. British Journal of Healthcare Management, 244, pp.175–180. Emmel, N., (2014) Sample Size. In: Sampling and Choosing Cases in Qualitative Research: A Realist Approach. London: SAGE Publications Ltd. Erens, B., Wistow, G., Mounier-Jack, S., Douglas, N., Jones, L., Manacorda, T. and Mays, N., (2016) Early evaluation of the Integrated Care and Support Pioneers Programme. Policy Innovation Research Unit, p.183. Evans, J.M., Daub, S., Goldhar, J., Wojtak, A. and Purbhoo, D., (2016) Leading Integrated Health and Social Care Systems: Perspectives from Research and Practice. Healthcare Quarterly, 184, pp.30–35. González-Ortiz, L.G., Calciolari, S., Goodwin, N. and Stein, V., (2018) The Core Dimensions of Integrated Care: A Literature Review to Support the Development of a Comprehensive Framework for Implementing Integrated Care. International Journal of Integrated Care, 183, p.10. Goodwin, N. and Smith, J., (2011) The evidence base for integrated care. [online] Available at: https://www.kingsfund.org.uk/audio-video/evidence-base-integrated-care [Accessed 16 Apr. 2022]. Greenhalgh, T., Humphrey, C., Hughes, J., Macfarlane, F., Butler, C. and Pawson, R., (2009) How Do You Modernize a Health Service? A Realist Evaluation of Whole-Scale Transformation in London: Modernizing a Health Service, in London. Milbank Quarterly, 872, pp.391–416. Ham, C., Smith, J. and Eastmure, E., (2011) Commissioning integrated care in a liberated NHS. The Nuffield Trust, p.68. Hartley, J., (2004) Case study research. In: C. Cassell and G. Symon, eds. London: Sage Publications Ltd, pp.323–333. Jagosh, J., Stott, H., Halls, S., Thomas, R., Liddiard, C., Cupples, M., Cramp, F., Kersten, P., Foster, D. and Walsh, N.E., (2022) Benefits of realist evaluation for rapidly changing health service delivery. BMJ open, 127, p.e060347. Manzano, A., (2016) The craft of interviewing in realist evaluation. Evaluation, 223, pp.342–360. Maruthappu, M., Hasan, A. and Zeltner, T., (2015) Enablers and Barriers in Implementing Integrated Care. Health Systems & Reform, 14, pp.250–256. Pawson, R. and Tilley, N., (1997) Realistic evaluation. London ; Thousand Oaks, Calif: Sage. Sims, S., Fletcher, S., Brearley, S., Ross, F., Manthorpe, J. and Harris, R., (2021) What does Success Look Like for Leaders of Integrated Health and Social Care Systems? a Realist Review. International Journal of Integrated Care, 214, p.26. Tweed, A., Singfield, A., Taylor, J.R.A., Gilbert, L. and Mount, P., (2018) Creating allegiance: leading transformational change within the NHS. BMJ Leader, 23, pp.110–114. Westhorp, G., Prins, E., Kusters, C., Hultink, M., Guijt, I. and Brouwers, J., (2011) Realist Evaluation: an overview. Wageningen: Wageningen UR Centre for Development Innovation. Wistow, G., Gaskins, M., Holder, H. and Smith, J., (2016) Why Implementing Integrated Care is so much harder than designing it: experience in North West London. England. International Journal of Integrated Care, 166, p.308.  

A Realist Evaluation of ICS Leadership

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A Realist Evaluation of ICS Leadership

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