Contexts and complexities: a realist evaluation of integrated care system leadership.

Purpose: This paper presents a realist evaluation of leadership within an integrated care system (ICS) in England. This paper aims to examine which aspects of leadership are effective, for whom, how and under what circumstances.

Design/methodology/approach: Realist evaluation methodology was used, adopting prior realist review findings as the theoretical framework to refine explanations of how and why leadership within an ICS is effective. Between January and November 2023, 23 interviews with ICS leaders took place, alongside 7 meeting observations and documentary analysis. The Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) guidance informed the study design, conduct and reporting.

Findings: The findings highlight two overarching infrastructural contexts influencing leadership in ICSs: the impact of the post-COVID-19 pandemic legacy and the differences between health and social care regulatory and financial environments. Findings demonstrate that ICS leaders identified a strong sense of purpose as crucial for guiding decisions and creating a psychologically safe environment for open, honest discussions, fostering calculated risk-taking. Whilst a shared vision directed priority setting, financial pressures led to siloed thinking. Leadership visibility was linked to workforce morale, with supportive leadership boosting morale amidst evolving ICS landscapes and confidence in data-driven decisions supported prevention activities. However, financial constraints hindered responsiveness and innovation in addressing health inequalities.

Originality/value: By examining ICS leadership post-COVID-19 pandemic and amidst varying regulatory and financial environments, this study contributes to the emerging literature on systems leadership and offers practical guidance for leaders navigating the complexities of integrated care.