The paper seeks to assist public sector leaders to take a balanced and impactful approach to transformation programmes which aim to deliver integrated healthcare. The paper highlights the balance of attention paid in these programmes across elements of leadership, strategy, structure and people, and aims to highlight where this balance can sit to encourage more successful and sustainable transformations, with an increased focus on interpersonal and inter-professional engagement and interaction across workforce and service users.
The project involved a literature review which identified themes that were in turn used to inform an approach to a desk review of journal articles written about past integration programmes in healthcare. A coding framework was developed to assess the articles in the desk review to identify where the focus of attention lay in the approaches to integration.
There is a spread of activity across all four themes (leadership, strategy, structure and people) in the assessed cases, but the emphasis tends to be towards static, short-term approaches, with a noticeable lack of focus on the aspects required to deliver long-term sustained transformation. There is a need for improved balance between structural and relational approaches to transformation.
The paper focuses on nine examples of transformation programmes and would benefit from further development and use of the coding framework.
The framework that emerges from this project can contribute to the development of a proactive model to assist transformation leads and decision makers bring a more balanced, thoughtful and impactful approach to integrating health and care services. In particular, the findings point to an overuse of structural approaches to change and transformation, which could include project management methods, for example, which become the product of the initiatives, rather than enablers of leaders’ visions and people’s interpersonal and interprofessional engagement and interactions.
Building on existing research, this paper makes a valuable contribution to the discourse on how to deliver the required health and care integration agenda in a more accessible way and sustainably, moving away from short-term, quick-fix approaches and considers how to accommodate the role of interpersonal interaction as the vehicle for change.
1. Introduction
The recent Darzi review into the NHS painted a challenging picture of the “dire state” (Darzi, 2024) of the healthcare sector, highlighting amongst other things, a lack of patient voice and staff engagement alongside management structures and systems, as key contributing factors. Other factors include poor funding and the impact and aftermath of the Covid-19 pandemic (Darzi, 2024)
The sources of these challenges, and the attempts to resolve them are not new. For example, the perceived failure of the privatisation agenda in UK public services (Kekez et al., 2019) has led to an integration and collaboration agenda, particularly in health and social care services in England (The Kings Fund, 2021) which seeks to make services more accessible to those using them while also realising efficiencies through improved coherence and outcomes (The Kings Fund, 2021). While this agenda has been building over recent decades (Anderson-Wallace and Downham, 2024), issues including austerity, the Covid-19 pandemic and more currently the energy price crisis (Torjeson, 2022) have injected, what might be considered, the necessary sense of urgency (Kotter, 2012) to focus minds and deliver the required changes.
Public sector leaders have remained committed to delivering the transformations needed to realise the improvements required. Recent decades have evidenced a near continuous slew of often structural approaches to deliver services that are more preventative; more focused around the needs of service users; more efficient; more effective in terms of outcomes. At the same time, the challenges facing public sector delivery, particularly those in the “people” services to adults, children and families, have noticed increasingly stretched resources resulting in poorer staff wellbeing and reduced public satisfaction. The many attempts at improvement over recent decades have been “exceedingly difficult” (Anderson-Wallace and Downham, 2024) and have mostly failed to deliver improvements (Anderson-Wallace and Downham, 2024). Perhaps as a result, there is a growing research movement into delivering more consistent approaches to the required transformations. The Sustain Project, DMIC and Project Integrate are three well-established programmes in this arena, which this paper seeks to compliment.
In keeping with Lord Darzi’s findings, this paper sets out to explore and answer where activity and attention are placed in health and care transformation programmes, bringing particular focus to elements of leadership, strategy, structure and people. With significant effort and resource spent on public sector transformation over recent decades, often focused on increased service and workforce integration, it is important to understand where challenges to impact and success may lie, and this paper therefore introduces an accessible model to retrospectively assess the efficacy of transformation programmes and offers an opportunity to develop a proactive transformation framework to improve planning, impact and success.
The approach to change and transformation is not an uncontested arena. Communication as a way of enabling peer learning and knowledge share (Anderson-Wallace and Downham, 2024) is key to effective service integration and transformation which requires an accommodation of the needs of the people populating the service, organisation or system. The Kings Fund (2022) identify a difference between “partnership” and “partnering”, with the former being limited by the enduring unique contexts of each partner (also Olaitan and Pitts, 2020), while the latter brings focus to the activities of relationship-building, logistics and learning.
Anderson-Wallace and Downham (2024) also reflect on two approaches leaders might come to occupy on the journey to transformation. They term these “miners” and “travellers”, with the former seeing their role as creating the system conditions to then drill down for root causes to be fixed through the process of change. Travellers on the other hand see themselves embedded within complex matrices of meaning and action, “active participants in an ongoing interactive emergent process”.
Similarly, Olaitan and Pitts (2020) highlight the challenges of “collaboration” and point to the work of Himmelman (1996) who distinguishes between what might be considered structural approaches to joint working (networking, coordination and cooperation) and the interpersonal interactions required of collaboration. Such distinction is reflected by Lawrence and Lorsch (1967) who identify the “unity of effort” required for “true integration”.
In addition, many researchers and observers have highlighted the need for storytelling and narrative building as key elements for successful joint working, integration and transformations (Centre for Public Impact, 2021; Davidson, 2018; Meadows, 1999). What these all have in common is an assertion that reality is socially constructed and to deny the humanity of the systems in which change is being attempted will often lead to poor outcomes.
This paper builds on these perspectives, seeking to find a balance between the need to accommodate social interaction and the effective structures which enable a realisation of the vision for change, the strategy to get there and the engagement and empowerment of people to lead and embed the transformations desired.
However, what this project has highlighted is that often more attention is paid to structural approaches to change and transformation, and this is at the expense of the necessary focus on people, in many ways reflecting the findings of the aforementioned Darzi Review.
There are various reasons for this, not least the tendency for leaders to focus on the tangible and objective over the subjective (Goold and Campbell, 2002). Therefore, leaders may benefit from introducing structures that enable social, interpersonal, inter-professional interaction through the establishment of what this paper refers to as collaborative knowledge networks. These can serve the dual purpose of supporting participants to better understand their own value and agency as a platform for more productive and meaningful engagement and contributions, while also providing the space through these networks to bring attention to the focus of transformation. This approach represents a structural arrangement that enables the workforce to engage, interact and deliver through collaborative, constructive communication without needing to take time away from service provision. This “enabling” (Donabedian, 1966 and 1980) function of structural responses to change is the key takeaway from this project.
The paper is of interest to a broad range of readers interested in public sector reform but more specifically senior leaders, decision makers and commissioners will find it useful in their own transformation programmes seeking improved integration and collaborations.
The implications of these findings point to a need to develop training for leaders and change agents highlighting these enabling structural approaches to support the meaningful engagement and enablement of staff and service users to inform and implement change. Such models can also promote a move away from pluralistic frames of reference, bringing service users, leaders, managers and staff into a combined consideration of “people”, and the unitary frame of reference required to encourage alignment and collaboration – bringing all voices into one conversation through these effective networks – from fragmentation to coherence through collaborative, constructive communication.
2. Method
Q-Sort is a research technique more commonly utilised in questionnaires and interviews with respondents and it’s not typical to see this methodology applied to desk reviews. However, a Q-Sort methodology can be useful in introducing somewhat of a quantitative element to what might otherwise be subjective constructs as part of a qualitative approach, such as a thematic analysis desk review, as utilised in this study.
For this study a number of literary papers were reviewed to identify constructs that could inform the Q-Sort. According to Gray (2020) it’s important that such constructs have a high degree of “face validity” by deriving them from previous studies or expert opinion, rather than simply being plucked from thin air. The use of literary papers in this regard aimed to meet this purpose. The constructs identified were:
Leadership
Strategy
Structure
People
See “Developing the coding framework” for more on how these were identified.
The validity of these constructs, or “key elements” as defined in this study, was further enhanced by reviewing established academic literature to identify characteristics of these key elements. These characteristics were labelled as “sub-elements” in this study.
A further series of journal articles were selected and reviewed to identify how many incidences of each sub-element were present in each paper. Such an approach meets that suggested by Ekinci and Riley (1999) in Gray (2020) in that it:
Creates the construct definitions (key elements)
Creates a set of statements (sub-elements) that represents the key elements
Tests the sub-elements by identifying their prevalence or lack of prevalence in each of the journal articles. The “free sort” criteria for this study were simply “present” or “not present”, as opposed to “agree”, “disagree” and “don’t know/no opinion” that would be seen in a more typical, interview/questionnaire respondent deployment of a Q-Sort methodology.
Such an approach ensured the analysis of each journal article was conducted in a consistent way. This was important given the subjective nature of the study in that it was down to the researcher’s perception to assess the journal articles against the sub-elements, which would have lacked any form of consistency without this adaptation of the Q-Sort methodology and wouldn’t be replicable by another researcher without this approach.
Search criteria for the literature review included articles written in English and presented in journals covering aspects of team development, health and care, service integration, interpersonal collaboration and sourced from anywhere in the world. The studies could explore cross-organisational, cross-professional and/or cross-sectoral integrations and collaborations. Articles were sought that had been published since the year 2000.
The core activity of the project was conducted through a subsequent desk review of journal articles discussing health and care integration programmes meeting the following criteria:
Have occurred anywhere in the world and written in English
Between 2010 and 2022 to ensure the programmes were informed by the policy and legislative agenda of the time – such as the NHS Five Year Forward View, The NHS Long Term Plan and the UK Government White Paper “Working Together to Improve Health and Social Care for All”, and similar, subsequent publications reflecting such public sector policy.
Focused on community-based health and care integration, particularly, but not exclusively, those programmes of integration between primary care and social care.
Search terms included systemic leadership, collaborations, integration, team development, team building, health and care integration, public sector integration, collaborative learning in integrated health and care, workforce in health and care integration and collaborating across organisations.
The desk review wasn’t focused on the particular transformation programmes being presented, but instead sought to identify themes across these examples of health and care integration through the lens of “leadership”, “strategy”, “structure” and “people” – the key elements.
Table 1 provides a list of the nine titles used in this study.
3. Developing the coding framework
Firstly, the main criteria for coding were identified through the literature review, which highlighted the role of “leaders” in the process of transformation, but also the role of learning and social education. In particular, the literature review suggested the role of leadership was emphasised while the role of people’s interactions through learning and social education was not afforded the attention it perhaps required. This led to the identification of “Leadership” and “People” as two “key elements” to measure in the cases.
“Structure” was identified as a useful key element as the literature review identified “structural integration” (e.g., Shand and Turner, 2019) as increasingly notable in attempts to improve the delivery of health and care. Such structural integrations can be seen in developments including clinical commissioning groups, accountable care organisations, accountable care systems, sustainability and transformation partnerships and integrated care systems, each of which have contributed to shaping the health and care landscape in England since 2012.
Finally, the label “strategy” was adopted as a helpful key element to consider how the leadership vision might be translated into action, through the identified structural considerations. Therefore, the four key elements in the framework were:
Leadership
Strategy
Structure
People
“Sub-elements” were then created by reviewing how these key elements were defined in established academic textbooks, so they could serve to define the use of the key elements. However, to create the sub-elements for the “people” key element, the Interprofessional Capabilities Framework (Walsh et al., 2005) was reviewed alongside the outputs from the literature review to identify commonalities in assessing the capabilities needed for interprofessional working that can deliver the required collaboration and integration. The product of this was employed to identify actions and outcomes that would define an active involvement of human interaction to inform the delivery of health and care.
Table 2 sets out the resultant framework utilised to assess the data.
The outputs from this exercise were then manually reviewed and analysed.
4. Findings from applying the framework
Figure 1 shows an example of how the outputs from the coding framework were captured.
Table 3 shows the numerical and proportional outputs from the desk review.
5. Discussing the findings
This study investigated the prevalence of leadership, strategy, structure and people in health and care integration across multiple cases. These findings are synthesised with four established models and research programmes—Project INTEGRATE (Cash-Gibson et al., 2019), The SUSTAIN Project (de Bruin et al., 2018), The Developmental Model for Integrated Care (Minkman, 2012), and McKinsey’s 7S framework (mckinsey.com, 2008)—to provide a comprehensive understanding of how these elements contribute to integrated care outcomes.
5.1 Leadership
The analysis reveals significant gaps between high-level vision-setting and the operationalisation of strategies. In the studied cases, L1 (setting a vision) is consistently and highly prevalent, but L4 (establishing goals) and L6 (developing the most effective strategy) are underrepresented. This suggests that while leadership is effective in outlining the overarching vision, there is less focus on defining concrete goals and creating detailed strategies to achieve them.
Comparison with Research Programmes:
Project INTEGRATE emphasises the role of leadership in fostering coordination between services and maintaining a shared vision across stakeholders, which aligns with the findings on the importance of vision-setting (L1). However, similar to our study’s cases, it also identifies gaps in translating vision into actionable strategies.
McKinsey’s 7S model supports the notion that strong leadership is necessary to align “shared values” and the vision of integration. The findings highlight a need for more robust goal-setting and strategic involvement, echoing the lack of focus on L4 and L6 in both our cases and Project INTEGRATE.
The SUSTAIN Project emphasises that leadership must not only define a clear vision but also engage in the continuous development of strategies that ensure sustainability, pointing to a gap in leadership’s focus on long-term planning in the studied cases.
Implication: While leadership is key in setting a vision, both the research programmes and the cases show a common gap in operational leadership, where concrete goals and strategic planning fall short. Effective leadership in integration needs to go beyond vision-setting and focus on clearly defining goals and measurable outcomes.
5.2 Strategy
The findings on strategy show a significant gap in defining and communicating how success will be achieved. Strat1 (management of resources and competences) and Strat2 (respond to the threats and opportunities in the environment) appear somewhat frequently, suggesting a familiarity with established project management and strategy tools. However, there is a critical lack of attention to Strat3 (identify the long-run goals and objectives), Strat5 (defining what success is) Strat6 (communicate how we get there), Strat7 (a coherent and consistent stream of policies and actions) and Strat8 (evolution of the basic mission). This suggests that while resources and competences are being managed, strategic communication and clear definitions of, and approaches to achieving success are lacking, which can lead to disjointed efforts in integration. These outputs also mirror those seen in the Leadership key element above.
Comparison with Research Programmes:
McKinsey’s 7S model stresses that strategy must align with structure and processes to ensure cohesive integration. The findings reflect that while the management of resources (Strat1) is addressed, there is insufficient communication of the strategy (Strat6), a critical factor for maintaining alignment across teams.
Project INTEGRATE and The Developmental Model for Integrated Care also underscore the importance of a clear strategy that defines success in integration efforts. Both programmes suggest that without a well-defined strategy and success measures, integrated care initiatives may struggle to deliver sustained improvements, a sentiment echoed by the gaps in Strat5 in the cases studied. In addition, the findings from the cases suggest that while resources are managed (Strat1), these initiatives often lack the adaptable strategies necessary for long-term success.
The SUSTAIN Project highlights the importance of aligning strategy with sustainability, reinforcing the need for long-term strategic planning that goes beyond resource management. The lack of attention to defining success (Strat5) in the studied cases mirrors the challenges of sustaining integrated care without clear, measurable outcomes.
Implication: Across both the cases and the research programmes, there is a recognised need for stronger strategic planning that not only manages resources effectively but also clearly defines and communicates success criteria. A failure to define success (Strat5) and communicate strategic direction (Strat6) limits the ability to achieve long-term integrated care outcomes.
5.3 Structure
Structure emerged as the most prevalent key element in the studied cases, particularly Struc1 (how the organisation, talent and assets are organised and aligned). This focus on structure aligns with the perception that tangible approaches, such as reorganising resources and aligning organisational structures, are critical for integration. The literature pointing to a preference for the tangible over the less predictable also aligns here. However, the cases showed less emphasis on delivery and execution (Struc4 delivering the main activities of the enterprise), indicating that while structures are put in place, the processes to ensure their effectiveness are less prioritised.
Comparison with Research Programmes:
McKinsey’s 7S model stresses the importance of aligning structure with strategy, systems and staff to achieve effective integration. The strong emphasis on Struc1 aligns with this, but the limited focus on Struc4 highlights a gap in translating structural approaches into tangible outcomes.
Project INTEGRATE similarly emphasises that while structural alignment is necessary, it is not sufficient to achieve integrated care; effective implementation and delivery processes are critical. This supports the inference that the cases may be over-relying on structure without paying enough attention to how those structures are executed in practice.
The SUSTAIN Project and The Developmental Model for Integrated Care focus on flexible and adaptable structures that can evolve to meet the needs of integrated care, which would be reflected in Stat4 in our study. This points to a potential risk in the cases studied: the heavy emphasis on static structures may not support the dynamic needs of evolving service user, workforce and system requirements.
Implication: Structural alignment is crucial, but both the research programmes and the case data suggest that an over-reliance on structure without attention to execution (Struc4) can undermine the effectiveness of integration. Programmes need to ensure that structural approaches are supported by responsive processes that deliver practical results.
5.4 People
Despite the growing recognition of the importance of human-centred approaches, the people dimension shows significant variation across the cases. P1 (promoting respect for the cultures, values and beliefs of other professionals) was one of the more prevalent sub-elements, indicating a focus on fostering professional respect and collaboration. However, P2 (care provision developed in response to patient/service user choices) and P9 (service user involvement in design and delivery) were less prevalent, suggesting a gap in service user engagement and co-design. This suggests ongoing challenge in ensuring that integrated care models are truly responsive to the people they serve and engage. While P6 (care informed by a demonstration of interpersonal skills) suggests some progress towards capitalising on multidisciplinary opportunities, this is somewhat undermined by the significantly lower prevalences for P3 (understanding legal, statutory and regulatory requirements across professional boundaries), P4 (policy and practice to influence changing role boundaries), P5 (care informed by an integrated care plan) and P7 (a proactive contribution of uni-professional skills and perspectives to the interprofessional discussion and practice), suggesting, in keeping with the other key elements, that progress towards implementation to achieve sustained transformation remains a challenge.
Comparison with Research Programmes:
The SUSTAIN Project emphasises patient-centred care as a key aspect of sustainable integration. The low prevalence of P2 and P9 in the cases indicates that patient/service user involvement in the design and delivery of care models remains a challenge. SUSTAIN advocates for a stronger emphasis on incorporating patient preferences into care provision, a sentiment echoed by this study’s findings.
Project INTEGRATE and The Developmental Model for Integrated Care similarly highlight the importance of relational care, which requires active participation from both professionals and patients. The prevalence of P1 (respect for professionals) aligns with this, but the lack of attention to service user involvement (P9) suggests a missed opportunity for co-production in care models.
McKinsey’s 7S model supports the importance of aligning people with the shared vision and strategy of the organisation, underscoring the need for mentoring, coaching (P8), and service user involvement to ensure that integrated care is responsive and adaptive to human needs.
Implication: While professional collaboration is recognised, both the cases and research programmes point to a critical gap in service user engagement and co-design, alongside a lack of meaningful progress towards creating the cultures of collaboration amongst disparate workforce roles. Sustainable integrated care requires a greater focus on involving service users in the design and delivery of services to ensure care models are truly responsive to user needs. Without active engagement from service users, integrated care risks being out of touch with the needs of its users. Without meaningful cultures of collaboration amongst the workforce, it may be difficult to create the spaces for meaningful service user engagement.
5.5 In summary
This synthesis of the case data with findings from the four integration programmes/models highlights several key insights into the effectiveness of health and care integration. Leadership and structure are consistently emphasised, but significant gaps remain in strategic planning, goal-setting and meaningful service user/workforce involvement. The review of the cases indicates a willingness to talk about and be seen to do something about delivering change, but perhaps shying away or lacking the conviction or ability to nurture and implement the relationships, cultures and structures required to sustainably develop and embed the stated objectives of the transformation programme.
The research programmes reinforce the need for clearer strategies, measurable success criteria and stronger service user co-design processes to achieve sustainable outcomes. Moving forward, integration programmes need to balance structural responses with relational care, ensuring that leadership, strategy and people are aligned in delivering responsive, service user-centred care.
6. Discussion
The purpose of this project was to identify where activity, energy and consideration were applied in a range of health and care transformation programmes. The nature of each individual programme being discussed was not the focus. The motivation for the question was an assumption that too little consideration in such programmes is applied to the role and function of people, who will be required to inform, understand and implement the requirements of these transformations. While conducting this project, several established models and frameworks were identified which each recognise the role people should play to encourage integration programmes to succeed. So, people-centredness is not a revolutionary finding if this project. However, it is of note that this project identified this still not to be the case in many integration examples. This distance between intention and application has been identified in the work of Project Integrate and Project Sustain.
In addition, the assumption was that considerations of leadership in the studied cases would suggest that disproportionately high levels of activity would be identified, perhaps as a result of hierarchical, top-down, command-and-control approaches to public sector leadership (Hunt, 2022).
It is of interest that the findings point to a far more complex set of circumstances and considerations. Davis et al. (2013), cited in the literature review, identified structure as a common focus in service integrations, which has also been noted by The Health Foundation (2021). As a result, Davis et al. (2013) also call for increased attention on how practitioners make meaning from these structures (Davis et al., 2013).
In the complexities of real-world delivery, it can become tempting to see project management tools and similar structural approaches as the change process itself, which some observers feel have come to characterise improvement efforts (Anderson-Wallace and Downham, 2024) at the expense of more “socio-culturally informed” approaches. Progress may then become defined by the production of governance structures, Gantt charts, stakeholder maps, databases, resource lists and logs, etc. The opportunity to see these completely useful and legitimate tools as enablers of the less tangible but possibly more impactful vehicles (Meadows, 1999) of change can be lost. Sometimes governance structures and frameworks can be experienced as restricting rather than enabling progress towards transformation. Other times, the development of a multidisciplinary team – “structure” – can be seen as an end in itself, without the necessary enabling consideration for how practitioners from such disparate backgrounds will actually relate to each other through considerations of power, influence and experience – “people” – (Anderson-Wallace and Downham, 2024)
Striković and Wittman (2022) identified the complexities that practitioners face in integrated settings and the need to promote a more collaborative, relationship-based approach to organisations trying to integrate (Olaitan, 2020) while Daft et al. (2020) suggest collaboration is useful in bringing organisations together to reduce tensions and frictions and focus on common value offerings. These calls align well with policy frameworks (NHS, 2014; NHS 2018; NHS 2019) which point to contingency approaches (Champoux, 2020; Smith et al., 2013), via integrated and collaborative care models. However, Olaitan and Pitts (2020) highlight the challenges of realising effective collaboration in the public sector, which Goold and Campbell (2002) suggest is due to leaders tending to favour the tangible rather than the less predictable.
The findings in this research confirm the assertions of these authors, particularly when looking at the prevalence of particular sub-elements in the coding framework, which showed a significant focus on structure. A wide range of authors have pointed to the ways in which our personal and interpersonal drivers and experiences shape and inform our behaviour, suggesting a focus on structure alone is insufficient to deliver lasting change. Bourdieu’s (1991) “habitus” points to the way our behaviours are driven by environment and circumstance; Goffman (1959) discusses the “fronts” we use in our presentations of self; Tversky and Kahneman (1973) discuss the “availability heuristic” which causes us to preference the familiar; Campbell and Groenbaek (2019) discuss the “positions” we take in relation to the positions those around us occupy. None of these tensions and opportunities can be accommodated without a specific focus on people and the way they relate to, and within, the prescribed structures. For this reason, structures should be developed as enablers of people’s interactions rather than setting out to define the spaces people are expected to occupy.
However, when reviewing the themes in the coded data, it appears that attention is paid, somewhat, to each of the key-elements across all the cases, but there is a lack of attention paid to those activities that might be considered necessary to embed change sustainably and deliver the sought-after “second and third order change” (Bartunek and Moch, 1987). The suggestion here is that the findings in this project may only result in “first order change” (Boonstra and Bennebroek Gravenhorst, 1998) in the transformation programmes studied, failing to challenge the established and embedded powers, structures and legacy systems (Markides, 1998) in place, which may limit sustained change. Which is problematic, and further points to the complexities leaders must navigate.
This project has been informed by the belief that organisations are populated by people who share knowledge and experience, which generates new knowledge to shape practice, processes and policies (Maltby and Anderson-Wallace, 2016). However, it is felt, this understanding is often overlooked in favour of more tangible and seemingly objective and measurable aspects of organisational experience, which are perceived to convey greater confidence and assurance to leaders and decision makers. Often captured in the term “managerialism” (Barlow and Scott, 2010), there is a demotion of the subjective and a desire to quantify things into measurable units, which consequently limits the opportunities for people to define the organisational space and what takes place within it.
For these reasons we propose the development of new structures deliberately shaped to enable social interaction, bringing service users, workforce, leaders and managers together to share knowledge and experience, recognise how we consider and engage with ourselves and each other and embrace the generation of new information and knowledge through these social interactions. We call these enabling structures “collaborative knowledge networks” in recognition of their function to facilitate the identification and sharing of knowledge and experience, embrace the uncertainty and complexity of people (Ganz, 2011), and facilitate space for vision and narrative generation. To encourage these collaborative knowledge networks to function as safe and equal spaces, participants are collectively introduced to concepts and models designed to open up thinking and consideration of how we conceptualise, consider and interact through such models as domains of action (Lang et al., 1990); mental models; mindfulness; appreciative inquiry; curious and critical thinking; reflecting groups and other concepts that encourage the development of collective narratives and visions for change that bridge the social spaces and bring participants into the process of defining the route to sustainable change. Given the significant strain on capacity in public sector settings, these collaborative knowledge networks need to be located in the arena of delivery and focused on the programme of change, rather than set aside as a separate activity on top of participants’ main role. Effectively, collaborative knowledge networks become ways of learning, knowing and working via a vehicle of collaborative, constructive communication.
7. Conclusions
It is overly simplistic to point to established hierarchical, top-down models of leadership in the public sector as solely responsible for a lack of meaningful engagement of practitioners and service users in health and care transformation programmes. Indeed, Harris et al.’s. (2022) call for a focus on education for leaders, points to the understanding that leaders should be considered part of the workforce, part of the “people” key-element and as such deserving of consideration for the complexities they face and seek to lead and manage, which may support a shift from the current pluralistic frame of reference (Rees, 2015), with competing voices and demands, to the unitary frame of reference (Rees, 2015) required to encourage alignment and collaboration across leadership, workforces and those accessing services, bringing all voices into one integration conversation.
As such, it should be recognised that in dealing with such complexity, support, guidance and learning should be arranged and made available to leaders with the specific aim of helping them navigate the requirement to meaningfully engage, enable and empower practitioners and service users to make meaning in transformation programmes so they can develop their own emergent solutions to change (Burnes, 2017). Many authors (for example, Burgess et al., 2022; Lynch, 2021; Bessant and Tidd, 2015; Desouza, 2011) point to the need to develop networks, cultures of learning and space and time to convert tacit knowledge into explicit knowledge, through social interaction, to achieve this.
Accessible models of best practice should be developed and shared which promote meaningful engagement, enablement and empowerment of service users, practitioners, managers and leaders to make meaning of transformation expectations and develop solutions to implement and embed them, which promote interpersonal professional relationships. It is for this reason we have developed and proposed collaborative knowledge networks to support this required transition from structural to structurally-enabled social approaches to transformation.
