Paradoxes of Multi-Level Leadership: Insights from an Integrated Care System

ABSTRACT In this paper, we draw on systems leadership, complexity and paradox theory to elucidate the tensions that organizational actors experience when practising multi-level leadership. We explore these issues through a study of the perceptions and experiences of stakeholders within an Integrated Care System (ICS) in England. Employing a collaborative inquiry approach, data were collected via 19 narrative interviews with participants in key leadership roles across ICS partners and nine co-creation workshops with a total of 86 participants from different parts of the ICS. Findings highlight that in developing multi-level leadership practice, leaders experience contradictory expectations and outcomes, including paradoxes of identity, place, purpose and change. We conclude by suggesting that leadership in multi-level contexts requires oscillating between competing polarities in a dynamic equilibrium with attention to localized interactions. MAD statement Integrated Care Systems were enacted across England in July 2022 to enhance the capacity for statutory, voluntary and community organizations to work in partnership to improve health outcomes across diverse populations. Multi-level systems leadership, however, poses significant challenges around navigating the inevitable tensions that arise when working with complexity. Through qualitative research in a vanguard ICS, this paper highlights a range of paradoxes faced by leaders and organizations and proposes implications for policy and practice in enabling dynamic equilibrium and working in contexts of uncertainty and change.