Table 1.

Definitions of the final mechanisms at Stage 1b.

MECHANISM	DESCRIPTION
Inspiring intent to work together	Integrated care teams and systems have no statutory basis but depend upon voluntary collaboration between NHS and local authority leaders to develop a shared, system-wide approach to strategy, planning and commissioning, financial and performance management. Leaders are effective as advocates for integrated care and for inspiring intent to collaborate with staff across the system and outside it, at various levels. They have a supportive management style that promotes team cohesion, trust, respect, reciprocity and collaboration. Not only do leaders champion these values in their own conduct but they also promote them in their staff. They empower and inspire participation from all professionals, use ‘public narratives’ where appropriate and prevent resistance behaviours, ensuring that key values such as cooperation, openness and fairness are instilled into the fabric of the service.
Taking a wider view	Integrated services involve cross-boundary working with a wide and varied group of organisations and people with a plurality of interests, goals, aspirations and values. Leaders of integrated teams and systems have experience and insight into the motivations and challenges of other organisations and focus on the bigger picture by acknowledging the importance of making strategic connections with leaders in other parts of the system. They use this knowledge to engage with other leaders, be convincing/persuasive in their communications with others, work through challenges in partnership with other organisations bridging language, thought, world, and goal differences that may otherwise prove detrimental, to come up with collective solutions and to look beyond reactive problem solving by taking a longer-term strategic view. Their political astuteness is a necessary and beneficial set of skills that enable them to get things done for constructive ends. Consequently, the goals of the team are more likely to be achieved. However, political astuteness can also be used to pursue personal or sectional interests.
Creating the conditions to work together	Different organisations, teams and individuals bring their own organisational, sectional or professional interests, ways of working and cultures. Leaders of integrated teams understand, are committed to and champion a shared philosophy, shared mental models and a common mission/vision/purpose for integrated services. Leadership is fundamentally more about participation and collectively creating a sense of direction than it is about control and exercising authority. They provide a clear narrative and direction for their team members to enable and encourage them to align their goals, have a shared focus and to engage in integrated working, rather than think about their own clinical teams, organisations or personal needs. They offer team members a sense of common ownership of the team and its reputation, are willing to delegate responsibilities and provide their colleagues with shared responsibility/accountability for financial, cost and quality targets. As a consequence, role defensiveness or ‘turf wars’ are limited, decision making is assisted, and effort becomes more focussed during times of conflict and disagreement.
Clarifying complexity	Many complex and challenging conditions are associated with integrated working, with unclear boundaries, structures and processes, different governance procedures and funding streams but leaders can navigate the tension between certainty and uncertainty and translate this to their teams and/or systems. Leaders employ sensemaking strategies, in which they use a set of available artefacts in order to make the understanding of their message clear and internalised. They are successfully able to negotiate the narrow parameters between oversimplification and exclusionary detail, enabling team members to understand the complexity of disparate policy drivers, legislation, performance requirements, regulatory systems and funding mechanisms to ease working arrangements for the team. They do this by developing policies and initiatives that are easily communicated and understood, with documents explaining how decisions are made and who has the authority to make them. This prevents confusion and enables team members to navigate organisations with multiple decision-making bodies.
Planning and coordinating	Leaders coordinate, strategize and serve as a liaison and boundary spanner between their team and the other teams in the system. They actively plan and synchronise the teams within the system, aiding the teams with their timing and executions of plans and helping them to organise intrateam processes with inter-team processes and decision making. When component teams struggle to perform their tasks due to high workloads, leaders can provide backup behaviours by prompting other component teams to provide help, shifting workloads to other teams or proactively offering to help with specific tasks. They employ smooth coordination processes that provide the necessary capacity to the whole system to move nimbly and synchronously. This strategizing and coordination improves both team processes and system performance. However, system leaders must also be mindful of changing and competing demands and be able to switch quickly from the routine to the non-routine. Thus, leaders of systems devote time to ensuring system flexibility. If unexpected changes occur and contingency plans no longer seem appropriate, leaders decide whether to reconsider, abandon or adjust the original plan.
Balancing multiple perspectives	There is historic power imbalance between health and social care (e.g., between care homes and the NHS) and between professional disciplines. Leaders ensure balance between the organisational cultures, social mission and business aims of the organisations due to having several specialist areas of knowledge and a good understanding of a broad range of topics. They are enthusiastic ‘change agents’ and demonstrate full, visible and sustained support for service integration. They advocate for those organisations that need greater power and are willing to have difficult conversations with colleagues across different organisations and specialisms and to deal with the uncertainty and ambiguity inherent in complex adaptive systems. This enables greater collaborative and equal working across organisations. Leaders are also able to create balance between professional hierarchies within the team and manage conflict between team members appropriately, working with, and negotiating with, many different stakeholders who have divergent values, goals, ideologies and interests. Leaders recognise tension and work through it with staff in order to develop a condition in which it is safe to challenge, and discussion becomes healthy. A productive balance between harmony and healthy debate is maintained and a coalition is created, with a degree of actionable shared purpose.
Working with power	Leaders have an awareness of power dynamics and know that the appropriate use of power within and across teams and organisations can be critical during times of uncertainty. Leaders are aware that power dynamics should be skilfully and intelligently negotiated and recognise that colleagues in other parts of the system are sometimes in a better position to lead on certain initiatives than themselves. In such circumstances, they are willing to shift power, migrate authority and relinquish control where appropriate, i.e. if better outcomes can be achieved. When leaders are unwilling to relinquish control, progress can stall. Leaders step aside, showing interest but not interference and steering. They are also aware that tactics for reducing resistance to change based on threats, manipulation, or misinformation are likely to backfire. Leaders use referent power to bring their teams together (i.e., a charisma that makes others feel comfortable in their presence). This leads to higher team satisfaction during the process of change. Because referent power generally takes time to develop, this finding may highlight the importance of placing individuals who are known, liked, and respected by employees in transition-related positions.
Commitment to learning and development	Leaders have a strategic commitment to access external support and rapid learning with other like-minded systems. They are committed to reflecting upon and personally learning from a variety of sources, through formal and informal networks, and to act as a role model for team members, encouraging them to also learn and improve. Leaders establish communities of practice for team learning and the pooling of knowledge. Whilst managers apply proven solutions to known problems, leaders are exposed to situations in which groups need to learn their way out of problems that could not have been predicted. Leaders recognise that training initiatives can increase component team members’ awareness and understanding of their knowledge structures, as well as their ability to regulate then improve the effective coordination of the whole system under dynamic circumstances. They have an interest in innovation and creativity, inviting feedback and embracing change and evidence-based practice for continuous improvement. They encourage team members to generate ideas and explore possibilities but also have a tolerance for things not working and learn how to fail ‘well’.
Fostering resilience	Those providing public services need to deal with increased demand, higher expectations from the public about service standards, hostility and psychological projections from the public and the media, often in the context of declining resources for public services. The pace can be relentless and the physical, intellectual, and emotional demands very high. Successful leaders of integrated systems have both the personality and learned skills that foster high resilience, perseverance, and an awareness of the importance of remaining empathic to the public whilst also resilient in terms of their own wellbeing. They put in place social support systems (both within and outside work) and attend appropriate training and personal development programmes to strengthen resilience. Leader stress is therefore reduced.
Adaptability of leadership style	Leading an integrated team or system is difficult, given the complexities of moulding two or more organisations into one and the sense of loss or uncertainty that employees may experience as part of this. Collaborative leaders are able to adapt their actions based on the circumstances they confront. They acknowledge particular situations call for particular leadership skills and behaviours. Leaders align their styles according to the situation at hand, combining or switching approaches as necessary, changing strategy towards flexibility and the use of their tacit knowledge. This generates cooperation, cohesiveness and improved communication amongst group members.