Collaborative Leadership in Integrated Care Systems; Creating Leadership for the Common Good

ABSTRACT The COVID-19 pandemic has become a catalyst for change, but such change can only happen through collaborative leadership which maintains a focus on relationships and purpose rather than solely on outputs or outcomes. This conceptual article explores how health and social care integration has been offered as one potential solution to the challenge of health and social care transformation. Specifically, Integrated Care Systems in England are intended to provide regional governance, to provide public services in a coherent and robust way. We explore this development in relation to three key aspects: the macro-level global policy context; the meso-level organizational behaviour and culture; and the micro-level practice of individual leaders and managers. It is found that, whilst the organizational structure of Integrated Care Systems offers great promise, collaborative leadership is critical to realize truly resilient and sustainable collaborative relationships. MAD statement Integrated Care Systems have been developed at the system level with little consideration of the leadership that will be required to implement collaborative action across health and social care. Coming out of the COVID-19 crisis there is an opportunity to create leadership for the common good – but this will require energy, purpose, and courage across all levels of the governance system.


Introduction
Intractable and complex challenges are not new for those who work in the health and care sectors (Charles et al., 2019;NHS, 2014NHS, , 2019) ) but the COVID-19 pandemic brought these into sharp focus (Marmot, 2010(Marmot, , 2020a(Marmot, , 2020b;;Public Health England, 2020).What is clear (and has been for some time), is the need for leadership in response to complex challenges (Lichtenstein et al., 2006;Sullivan et al., 2012).However, what is especially evident, is that 'governance matters' (Hambleton and Rees (2020), p. 49), and the turbulent UK context of public services has demonstrated the requirements of governance to be considered across the domains of policy (macro-level), services (mesolevel), and practice (micro-level) (Ansell et al., 2021;Curry et al., 2022;VanVactor, 2012).
In keeping with the theme of this special issue we address the following research question: what characteristics of multilevel leadership are needed to support effective governance in Integrated Care Systems (ICS's)?In doing so, we provide a conceptual framework for the robust governance of service integration which may also serve as a theoretical guide for the empirical evaluation of collaborative leadership in health and social care services integration.This conceptualization employs contemporary theoretical debates on collaborative leadership in the context of complex public management (Eriksson et al., 2020;Osborne et al., 2015Osborne et al., , 2016;;Radnor et al., 2014) to address these recent calls for multi-level responses to governance, and thus presents a framework that advances the leadership and governance theories in a way that is complementary, and which keeps pace with the changing landscape of public service integration.
Leadership scholars have been criticized for espousing 'great man' theories for a rational world and increasingly it is recognized that these models are not fit for purpose (Getha-Taylor & Morse, 2013).Mangan and Lawrence-Pietroni (2019, p. 91) describe the leadership required today as ' … more rave than waltz' encompassing the challenge facing public sector leaders in tackling wicked problems (Grint, 2005) in a 'volatile, uncertain, complex, ambiguous, operating environment' ( Van der Wal, 2017, p. 30).Such changes can be seen in the shift from typically Weberian-based bureaucracies with rational professionals delivering to public citizens, to competitive entities driven by personal motivation, and finally to services that are designed with and for empowered communities (Osborne, 2010).These conceptual changes have been defined in the public management literature as traditional public administration to New Public Management, and New Public Governance, which imply increasingly adaptive (Heifetz et al., 2009), servant (van Dierendonck, 2011), and collective (Ospina, 2017) forms of leadership.
In considering leadership within the broader context of New Public Governance it is important to recognize that leadership can take place at multiple different conceptual levels (Batistič et al., 2017) between individuals, groups, and/or organizations.We also acknowledge leadership as a process and a practice as contrasting with the role of being a leader (Clegg et al., 2021).Current approaches to leadership research have given insufficient attention to multilevel approaches and analyses (Batistič et al., 2017) and have emphasized the leadership element above the public element of public leadership.Our research contributes to our understanding of the multi-level nature of public leadership by exploring the development of ICS's.We discuss how collaborative leadership may assist in realizing the potential of this new governance system at the macro-, meso-, and micro-level.In doing so we present a conceptual framework for analysis to inform future empirical research.
Shifts in the nature of public service delivery have been given special attention in the UK National Health Service (NHS) narratives of systemic change, and in the health and care sectors more broadly, where intractable and complex challenges are deep-seated (Charles et al., 2019;NHS, 2014NHS, , 2019)).Demographically, the population is ageing and consequently requiring higher-cost health and social care provision to meet complex needs (Birrell & Heenan, 2018).There are higher levels of degenerative disease, co-morbidities, and frailty (Sanders, 2018) which, along with improvements in diagnostics (Walshe & Smith, 2016) and screening (Ham et al., 2012), have led to an increased volume and complexity of need for the health and care system (Ham et al., 2012;Walshe & Smith, 2016).Further, economic pressures are set in the context of the 2008 financial crisis and constrained public spending typified in the UK by austerity policies (Lowndes & Gardner, 2016).These changes in market conditions in other sectors along with changing public expectations have reverberated through the health and care sector as can be seen in the application of technology, choice, and personalization (Birrell & Heenan, 2018;Ham et al., 2012).
The challenges facing all public services have been further exposed by the COVID-19 pandemic (Hambleton & Rees, 2020;Public Health England, 2020) which was not only a health crisis but exposed economic challenges and continuing levels of societal inequality (Hambleton & Rees, 2020).There is, therefore, now more than ever, an imperative to understand how public sector leaders can effectively lead within collaborative environments.This paper offers a conceptual framing for exploring the intersections of collaborative leadership, the governance of integration, and their intersections for producing collective good.First, we explore the context and challenge presented by Integrated Health and Social Care Systems.

Context and Challenge
The National Health Service is a highly complex, multi-faceted, multi-organization system which comprises over 200 NHS trusts, many other arm's length bodies and, until July 2022, over 100 Clinical Commissioning Groups, all working to deliver specific services for specific needs.There are different governance arrangements in each of the devolved nations of Northern Ireland, Scotland, and Wales who each have devolved responsibility for health policy.The NHS is 'free-at-the-point-of-use' operating separately from social care which is the responsibility of local government.Social care is delivered typically by private and third-sector (not-for-profit) organizations on a means-tested basis.However, there is a high level of interdependency between these sectors, and they are required to operate in coordination with each other.They are, therefore, part of a wider health and social care system of provision.
The high level of fragmentation in the health and social care system is reflected in the range of employers, financial systems, regulations, and accountability mechanisms (Birrell & Heenan, 2018).Previous attempts to enhance the integration of services often created unintended barriers to success (Hudson & Henwood, 2002).The introduction of internal markets and the import of business practices and values confounded progress (Hudson & Henwood, 2002) and have compounded the fragmentation of service delivery across the public sector including health and social care (Elliott et al., 2022).On the one hand, competition was intended to push down costs but, the unintended consequence of this fragmentation was inter-organizational dependence, the steering of which became much more complex and made integration at the service or policy level more costly and challenging to achieve (O'Flynn et al., 2011).Rhodes (2017), quoting Hesse (1991, p. 619), states: In this scenario, it is much more difficult to achieve 'collaborative, joined-up working … ' (O'Flynn et al., 2011, p. 253).
The latest attempt at developing greater collaboration between health and social care services is the development of ICS's.These are governance networks (now 42 in England) that bring together NHS commissioners and providers with local government and local partners to oversee health and social care in their localities.The first ICSs were developed in 2017 and the NHS Long Term Plan (NHS, 2019) confirmed that they would become the basis for future place-based health and social care through legislation in the Health and Care Bill (UK Parliament, 2022).They are intended to improve efficiency and patient outcomes (Curry & Ham, 2010;National Audit Office, 2017;Nolte & Pitchforth, 2014).
Figure 1 shows the range of organizations and relationships involved in ICSs.There remains, however, significant ambiguity around what integrated care means and how ICS's will operate in practice (Lennox-Chhugani, 2021).All ICSs are structured differently as there is no fixed model for how they should be developed; and the leadership is defined in terms of roles and agents, with little to guide leadership practices and behaviours in a complex, collaborative governance arrangement.In this sense they have been described as 'emergent set of practices' rather than 'a single intervention to achieve predetermined outcomes' (Hughes et al., 2020, p. 446).But what does this lack of clarity or direction mean for those leading these systems?
The research question we explore is what characteristics of multilevel leadership are needed to support effective governance in ICS's?We share Minkman's (2017) definition of governance, borrowed from Bevin: 'the total package of leadership, accountability and supervision in the local setting in an area or region' (2010: 1).With leadership and JOURNAL OF CHANGE MANAGEMENT: REFRAMING LEADERSHIP AND ORGANIZATIONAL PRACTICE accountability so embedded in the notion of governance, we propose that an examination of leadership accounts for three levels of interest; first, the macro-level global policy context; second, the meso-level of organizational behaviour and culture; and third, the micro-level of individual leaders and managers.New forms of governance call for leadership that sites accountability not only within organizations and structures but between them, enacted by all those involved in the creation and production of health (Nies & Minkman, 2015;Bingham, 2009).

Macro-Level Global Policy Context
Health and social care are multi-faceted complex services which are affected by a wide variety of extra-organizational environmental factors, including housing conditions, public transport, food policy, education, and many other policy areas (McDaniel et al., 2013).Equally, these services are influenced by external forces at local, national, and international level.They are also services which are highly dependent on effective citizen engagement, trust, and cooperation (Dudau et al., 2019).When accounting for human agency, health, and social issues are complex, multi-faceted, and problematic to address and so can be seen to fit the definition of wicked problems (Head & Alford, 2015;Rittel & Webber, 1973).
Many attempts have been made at an international level to address these wicked issues.For example, the Millennium Development Goals, established in 2000, included goals related to child mortality rates, maternal health, and infectious diseases such as HIV/AIDs.These goals were superseded by the Sustainable Development Goals (SDGs) in 2016 in which good health and wellbeing goals remain a core focus.The SDGs recognize the importance of mechanisms for better health outcomes including partnerships and cross-sectoral and cross-country collaboration.Yet what form of collaboration this should entail has been described as a 'Black Box' (Vazquez-Brust et al., 2020), and the membership across sectors is also contentious as third and private sector agencies may have contributions in such collaborative systems (Florini & Pauli, 2018).
Internationally there have been significant moves towards greater health and social care integration due in part to persistent health inequalities and global ageing populations (Carroll, 2021;Hughes et al., 2020).Yet there is little agreement on what precisely constitutes integrated care.In fact, the literature suggests some 175 definitions and concepts related to integration (Armitage et al., 2009) and evidence of their effectiveness is equally undefined.Guidance from supranational bodies, such as the World Health Organization (WHO, 2015), recognizes the challenges of fragmentation and complexity in delivering integration.
In the UK, the ambition to shift away from competition and organizational autonomy towards collaboration as set out in the Health and Social Care Bill (Kings Fund, 2021) belies decades of marketization and underinvestment.As recently as 2012 the Health and Social Care Act created a market for health services with the intent that competition would encourage innovation (Davies, 2014).Since then, the impact of the global economic crisis and subsequent austerity measures introduced in 2010 have limited any capacity for innovation and leadership development (Elliott, 2020).But, as noted by Bevir and Rhodes (2003, p. 58), the British State has been hollowed out over a much longer period of time from above (e.g. through international interdependence) from below (e.g. through marketization) and from sideways (e.g. by agencies and arms-length bodies).The impact has been particularly severe on local government who faced the largest public sector cuts as devolution policies in effect decentralized austerity (Lowndes & Gardner, 2016).The trends of fragmentation of providers, places, and professionals have continued (Elliott et al., 2022) and, when combined with the impact of austerity policies and the centralized political leadership of the NHS versus the local political leadership of social care have made it increasingly difficult to influence change (Elliott, 2020).This creates major questions over how and to what extent local government can play an equal role in collaborative governance systems created by integrated care.Measuring the impact of integration is complex, and the evidence about impact is mixed (Baxter et al., 2018;Kelly et al., 2020).However, leadership in a plural sense has a clear role in catalyzing integration, engendering a culture of working across boundaries and towards a common purpose (Curry et al., 2022).

Meso-Level Organizational Behaviour and Culture
The meso-level of organizational behaviour and culture is a confluence, where vertically, global, and national governance systems meet regional governance systems, and horizontally where regional governance systems meet local governance systems, stakeholders, and partners.This meeting of the vertical and the horizontal not only provides hierarchy but also breadth of governance across the system.Residing in this space, is the ICS, an intricate system of multi-level and, considering the horizontal or transversal aspects, multi-dimensional governance.If the ICS were to sit in isolation as an exposition of collaborative governance or regional governance system, that would itself be a complex, amorphous entity.However, as a governance system, the ICS does not exist in a silo, rather it sits amongst other similarly comprised systems, and each organization that forms an element of the ICS will also have its own multi-levels of governance.
ICS's are complex adaptive systems (Carroll, 2021), complex in this context relating to a system of 'rich interconnectedness and dynamic interaction' rather than a system which is purely complicated (Uhl-Bien & Marion, 2009, p. 632).Complex systems can adapt and learn as interactions occur (Holland, 2006).But leadership in such complexity is challenging (Mangan & Lawrence-Pietroni, 2019, p. 83), and classical theories of leadership, relying on a single figurehead to cast a substantial effect on the system (Van Wart, 2003), are quickly rendered unviable.The development of ICS's, therefore, provides an important context for the exploration of collaborative forms of leadership.
Complex Adaptive Systems provide a lens to examine the role that ICSs play in delivering health outcomes, and the requirements of contemporary public sector leaders (Mangan & Lawrence-Pietroni, 2019).Leaders working in a complex adaptive system are characterized by collectivist leadership which is person-centred (Carroll, 2021) and therefore requires leadership contributions from across multiple public service agencies.Collaborative leadership is key to ensure all aspects of the system work effectively, leadership occurring as a plural entity ('t Hart, 2014) undertaken by many actors across a system rather than by a single individual or organization.Considering an ICS as analogous to an engine, if one cog jams, the system does not work effectively, and often not at all.Collaboration 'implies a positive, purposive relationship' (Huxham, 1996, p. 82), providing direction to all the disparate parts of the system.
But what are the drivers for collaborative leadership across an ICS?The many and varied organizational building blocks of an ICS are subject to a range of regulatory and financial practices.Like an engine, in order to function well, the ICS must have a common purpose (Glasby & Dickinson, 2014).Collaborative leadership is necessary to ensure all elements of the system are operating in a synchronized way (Raelin, 2003).This harmony cannot occur through collaborative leadership solely at the top of the system or organization.Collaborative leadership needs to be distributed and embodied throughout the organization to achieve wider awareness of the system beyond the individual organization or actor and greater connectivity and interdependence across the system (Raelin, 2003).
This mode of leadership is the leaderful practice that Raelin (2003) proposes.A leaderful leader is in the position to 'shape the direction' of the organization (Raelin, 2003, p. 156).Each member of the community is a leader who may put forward views that contribute towards the 'common good of the community' (Raelin, 2003, p. 15) as a foundation for collaborative leadership, and can be supported through a process of leadershipmaking (Graen & Uhl-Bien, 1991).Yet often leaders within the health and social care sectors are expected to develop these skills without any formal guidance, support, or training (Elliott et al., 2020), and the consequence of austerity cuts, particularly on local government, means that such investment in leadership is even less likely to occur (Gibb et al., 2020).Raelin (2021) argues for the importance of the process of leadership and the richness of interactions, often achieved through storytelling practices (Boal & Schultz, 2007).In a diverse system such as an ICS the different perspectives of the organizations must be taken into account when considering purpose.The term 'embodied sentiment' (Raelin, 2021, p. 386) is helpful here, implying an overarching implicitly known sense of purpose rather than a specific goal or target.The definition of purpose used by By (2021, p. 36) works on a number of levels.
… the pursuit of a worthy idea and activity, the outcome of which goes beyond the individual and the individual organization.This explicitly references 'pursuit' giving an implicit notion of process, of working towards a common purpose and, in the context of this article, 'embodied sentiment' is reflected in the common good articulated through the SDGs.
Complexity Leadership Theory (Uhl-Bien et al., 2007) and its treatment of leadership as a social construction, fosters 'creativity, learning and adaptability' (ibid, p. 299).Leaders of complex adaptive systems prioritize learning and adaptation through interactions and dialogue (Boal & Schultz, 2007).The dynamic of adaptability aligns with the Integrative Collaborative Governance Framework (Emerson et al., 2012), which in turn captures the dynamic, collaborative nature of an ICS.This adaptive form of leadership Uhl-Bien et al. (2007) offers a further dimension necessary at this meso-level.
At this meso-level then, in a complex system, the intersection of multiple layers and dimensions of governance requires leadership which is collaborative, leaderful, and adaptive.To achieve a shift in culture towards this is imperative.It is this adaptive, inclusive, community-focused leadership which will breed sustainability in wider governance systems (Hambleton & Rees, 2020).This can be realized by asking 'How do we solve this problem together?' (Hambleton & Rees, 2020, p. 95).

Micro-Level Practice of Individual Leaders and Managers
Starting with the question 'How do we solve this problem together?' (Hambleton & Rees, 2020, p. 95), has a decentring effect on leadership.Leadership is no longer about the leader, but more about what can be accomplished through leadership (Raelin, 2016a).Leadership in this scenario is co-constructed by actors through the work of leadership to achieve a distinctive outcome (Raelin, 2016a).This is the micro-level of collaborative leadership underpinning collaborative governance and the proposition that what is vital in collaborative leadership is what happens between leaders in leaderful leadership.Essentially it is how actors work together to produce the desired ends.
Regional governance systems such as ICSs are messy and seeking clarity is a continual endeavour.Leadership that supports emergence relies on interaction through which collaborative agency is produced (Raelin, 2016b).Consideration of collaborative leadership as practice allows for an account of interconnected system actors and appreciates their agency and thus their ability to work within and across organizations (Sullivan, 2014).
This micro-level view of collaborative leadership in a practice-based view underlines the importance of a relational approach to leadership.In the relational model of leadership, leadership is considered as a phenomenon that arises in the relations between people (Fairhurst, 2007).In this model social interaction and communication are key in developing a shared reality and action (Fairhurst, 2011), founded on the way in which people relate to each other (Day, 2000).Lowe et al. (2021) propose that where services agree on a moral purpose, learning collectively across systems is the management strategy by which that purpose can be enacted.Through analysis of 48 case studies in the UK, Europe, and Asia, they have found that these leaders accept complexity's requirement for emergence in the delivery of services and service improvement, and thus embrace codesigned experimentation, collective sense-making, and system stewardship to learn together.
Connectedness, assert Ospina and Foldy (2010), is key to fostering collaboration, as leadership emerges through social interaction (Ospina et al., 2020).Ospina (2017, p. 276) argues that 'multiple relationships of accountability', such as in the ICS, present opportunities to explore the relational dimensions of leadership.Essentially what matters is what happens in the 'space between' (Bradbury & Lichtenstein, 2000, p. 551) and how interactions are used to produce and re-produce the understanding of purpose and governance responsibilities.Conversational travel offers 'moments of leadership' that can so easily be lost.How conversations 'travel' harnesses and builds on relational opportunities (Ramsay, 2016, p. 204) for connectedness and the emergence of collaborative leadership.It is necessary for actors in an ICS to harness such opportunities.
In these moments the way the conversations and relationships are handled can nurture or restrict the collaborative leadership efforts.Conflict and constructive leadership responses to events which are 'surprising, ambiguous or confusing' can provide, through the need to explain a situation, a way to sense-make and achieve deeper understanding and relations (Hartley & Stansfield, 2021) and encourage proactive engagement with tensions to facilitate operation in these more complex environments (Murphy et al., 2017).In practice, the multiple levels and multiple dimensions of governance impose varying regulatory and financial obligations as well as differing cultural and political JOURNAL OF CHANGE MANAGEMENT: REFRAMING LEADERSHIP AND ORGANIZATIONAL PRACTICE environments.Within collaborative environments there is a need for senior managers who are able to build relationships with other stakeholders and for all actors within the organization to be able to work across boundaries (Sullivan & Skelcher, 2002).This adds weight to the arguments for a leaderful, practice-based, relational approach which filters down to each actor within the organization.
Yet one of the persistent challenges here is how best to define appropriate leadership behaviours.Leaders working within the ICS as a multilevel system are working simultaneously both within their own organization and across the multiple levels of the system.Yukl's Hierarchical Taxonomy of Leadership Behaviours outlines four meta categories of organizational leadership behaviours: task-oriented, relations-oriented, change-oriented, and external (Yukl, 2012) behaviours.However, there are limitations to these behaviours for leaders working at a micro-level within the system but needing to be cognizant and have influence at the meso-and macro-levels.The relations element of Yukl's taxonomy (2012) describes the development of a human resource, and the external element refers to the promotion and defence of the organization.This provides primarily for an organization-specific set of behaviours and although relevant as a foundation for individuals in an ICS, is limited in the context of the breadth and depth of the multi-level system.Thus, further research is required to identify those broader set of behaviours, including those identified by Cunliffe and Eriksen (2011) and Crosby and Bryson (2005), that are required of leaders working within multi-level governance systems such as ICSs Crises as a Catalyst for Change Hambleton and Rees (2020, p. 49) concluded from their analysis of the COVID-19 pandemic that 'governance matters', and that improvement in multi-level governance is important.It is not sufficient to tackle a single level (Hambleton & Rees, 2020).COVID-19 has focused attention on robust governance at all levels (Ansell et al., 2021;Curry et al., 2022).Yet this is just one of several systemic shocks that could include the 2008 financial crash, austerity policies from 2010 onwards, the Brexit referendum of 2016, and most recently the Ukraine-Russia war.Cutting across all these socio-political shocks is the development of the UN Sustainable Development Goals, Agenda 2030 and Paris Agreement on climate change which have served to highlight the potential impact of the climate crisis and subsequent need for collaborative governance.
A theme prevalent in strengthening collaborative leadership is that of purpose and direction.The COVID-19 pandemic has provided a catalyst, a clear purpose around which all players in the governance frameworks can collaborate about 'shared intentionality' (Ramsay, 2016, p. 204) or 'embodied sentiment' (Raelin, 2021, p. 386).From the work with the community sector engaging minority ethnic groups in their own COVID-19 risk management and vaccination, to intersectoral collaboration on patient flow (Hiller et al., 2021), vital collaborative work has been led throughout the system.It is imperative that the momentum for collaborative working is maintained as crises move through different phases.There is particular emphasis here on the development of multilevel governance (Mejía-Dugand et al., 2020) of which we have established that the ICS is a key part.
Arising out of the COVID-19 pandemic is the double opportunity to harness the force for change and collaborative working alongside striving for the common good, and also to provide a clear purpose and sense of urgency (Mejía-Dugand et al., 2020) to channel collaborative leadership.The SDGs provide such a focus, providing a golden thread which reinforces vertical coordination and on a horizontal basis the 'holistic, multisectoral' collaboration (OECD, 2020).

Conceptual Framework for the Study of Multilevel Leadership in an ICS
In the introduction to this article, we set out the research question: what characteristics of multilevel leadership are needed to support effective governance in ICS'S?The article focuses on the circumstances of an ICS as an example of a multilevel, regional governance system which has the specific purpose of integrating health and care.A multilevel approach has been taken to elicit the features of collaborative leadership in this scenario at the macro, meso, and micro levels.Building on the work of The King's Fund (2021) the product of our undertaking is a conceptual framework visually represented in Figure 2.
In the context of the ICS, the intersection of collaborative leadership, governance, and multilevel leadership is a rapidly developing area of practice in which further research is needed to provide clarity and direction for those leading within such systems (Bolden et al., 2023).This conceptual framework provides a starting point for future research seeking to develop empirical findings and observations.This in turn has the potential to lead to concrete examples to inform how leaders can best work in these complex multilayer, multi-dimensional systems such as ICSs.

Conclusion
This article has explored the characteristics of multilevel leadership that are needed to support effective governance in ICS's and developed a conceptual framework to guide future research.In doing so, a three-layered approach has been taken at the macro, meso, and micro levels.
The macro-level takes the view that the SDGs provide a context for the common good and should offer a golden thread which permeates through the hierarchy of governance from macro-to micro-level, thus providing a clear moral purpose for the common good.At the meso-level, the ICS is situated in an important position of confluence of the vertical hierarchy of governance and the horizontal amalgam of partners and stakeholders.This is a complex, and at times, turbulent system.Good governance of this system relies on a collaborative approach and a clear purpose for collaborative leadership.At the microlevel a leaderful, practice-based approach to collaborative leadership builds on the relationships and knowledge of individual actors.Working towards a common purpose and moral imperative individual actors should seize the leadership opportunities that present.Using the analogy of a zip, opportunities for leadership must be taken at all levels to achieve the cultural zipping together of different organizations towards the purpose or 'shared intentionality' (Ramsay, 2016, p. 204) of achieving the common good.In this relational leadership context, it is how an individual actor acts or responds in their interaction that determines whether a moment of leadership can take place, or whether that moment is lost.
Leaderful practice throughout organizations is required to nurture collaboration.Having collaborative leadership solely between the senior levels of an organization leaves many operational parts disparate and isolated.It is the small connections 'between' that really engender the cultural shift in understanding and knowledge across the governance system.Professionals need to emerge from silos to collectively produce an understanding of the context for other parts of the system and how their parts contribute to the overall running of the 'engine'.
Reflexivity is a key element of collaborative leadership development.How did my actions contribute to the outcomes?How could I have changed the manner of engagement and interaction to effect the best possible outcome in the situation?How did my language facilitate the conversational travel towards a solution?How did I use conflict to open up the discussion to new ideas, to challenge and test?
Trust and respect are fundamental to underpinning this cultural shift.Alongside this, actors within regional governance systems should understand the role and place of other professionals within the system.In an ICS this would be NHS, local government, police, community, and voluntary sector.Scholarship in public administration is key to this understanding, bringing the sense of the clear purpose that underpins all those who lead our public services.The sense of the common good is there, it just needs highlighting in narratives of purpose to coalesce efforts.
Related to the sense of the common good is the need to hold in mind that at the macro-level, the SDGs, can provide the context for work at the meso-and micro-level.It is so easy to focus on the place and neighbourhood challenges of, for example, COVID-19 and Brexit, that sight is lost on the upstream challenges, which resolved, or eased, could really provide a unifying framework for common good work.As well as offering conceptual contributions on the multilevel characteristics of collaborative leadership, this article has outlined the beginnings of a conceptual framework for how future research on the intersections of leadership, the governance of integration, and collective good may be configured.

Figure 2 .
Figure 2. Conceptual framework of multilevel leadership in Integrated Care Systems.