Collaborative behaviours and leadership

While policy and system design often prioritise the ‘hard levers’ of contracts, governance and structures, sustainable integration depends on the quality of relationships and the leadership behaviours that operate in the spaces between organisations. Effective collaboration requires individuals across organisational and professional boundaries to have agency to share insight, influence collective priorities, and take shared responsibility for outcomes.

Trust, shared purpose and a collective commitment to improving population health are the foundations of these conditions. Without purposeful investment in relational development, leadership capability and environments that support joint problem-solving, even the most sophisticated governance and contractual arrangements will fail. As one ICB leader noted: “Contracts don’t deliver care – people do.”

In many systems, these enabling conditions are not yet fully established. Longstanding professional and sectoral identities, differing organisational incentives and entrenched cultural norms can reinforce siloed and at times protectionist approaches to decision-making. Strengthening systemic integration therefore requires a deliberate focus on fostering collaborative behaviours, building trust, aligning purpose and embedding the principles of contributory leadership into the way partnerships plan, prioritise and deliver care together.

Towards collaborative leadership

IHO host providers will need to move beyond institutional interests towards a shared, system-wide focus on population health and the delivery of the left shift, reducing avoidable demand for acute and emergency services through proactive, preventative and community-based care. Leadership will need to demonstrate ‘split-screen thinking’, balancing the legitimate operational and financial pressures of their organisations with collective accountability for population health outcomes and system performance.

To enable this, providers must feel supported and trusted to demonstrate the right level of risk appetite to shift resource upstream. This requires a move away from organisational sovereignty towards genuinely collaborative leadership, where system partners have strong levels of trust, co-own challenges, share data and insights, and work together to resolve tensions constructively.

Leadership within IHOs will need to be about convening rather than controlling, creating the space for shared purpose, joint problem-solving and inclusive decision-making. This represents a fundamental shift in mindset from traditional hierarchical leadership to a model of stewardship that operates across organisational boundaries. As one community and mental health trust leader put it, the host organisation must 'wear its contractual responsibility lightly, acting as a steward of partnership rather than a central authority.'

The incoming NHS Management and Leadership Framework provides a timely opportunity to embed these principles. Its focus on system leadership, compassionate management and distributed accountability aligns closely with the behaviours required for contributory leadership. By emphasising collaboration, learning and leadership across boundaries, the framework may help to strengthen the capability of leaders to work in service of the whole system rather than individual institutions.

In parallel, operational and structural barriers to collaboration must also be addressed. These include workforce passporting, single IT sign on, digital operability and data sharing, clinical risk management and incident learning. The host provider will also have to develop a financial strategy that aligns with organisational boundaries and encourages providers to move money between themselves in support of shared goals.

Contracting and sub-contracting will require high levels of trust, transparency and mutual accountability. The form this takes will vary from place to place, but the competencies underpinning convenorship and the ability to work in partnership with the ICB and other providers to define the parameters of the contractual agreement and how it is delivered should be a central part of the IHO approval criteria. 

‘Race to the top’

The new contracts outlined in the 10YHP give providers a stronger role in the allocation of resource and the coordination of care. For the first time, this positions providers to play a more direct and influential role in driving the left shift – a responsibility that has traditionally sat with commissioners and NHSE. 

This leadership should be perceived and exercised collectively across providers, rather than individually, with many healthcare leaders concerned that IHO status will be treated as a ‘badge of honour’ or a ‘race to the top’. As one ICB leader said: “The public wants safe, integrated care - not competition”, with an inherent contradiction in asking organisations to ‘prove’ who is the most collaborative. If this happens, there is a concern that IHOs undermine other recently developed partnership models, which have started to improve population health outcomes. 

There is also a practical implication of this competition. For example, how do you deal with circumstances in which two trusts both want to take on the IHO role in their local areas, or whether the authorisation of one IHO in a place would close off IHO status as a potential route for neighbouring trusts? To ensure relationships are preserved during this process, authorisation decisions and communications will need to be handled sensitively and transparently, while there is a clear convening role for the ICB in managing relationships locally.