Reflections in a Time of Crisis: What it Takes to Manage and Lead Integrated Systems of Care

For the past few years, we have been exploring the essence of management and leadership for integrated care, bringing together our respective research and substantive professional experience. We have led workshops, presentations and informal meetings including at the 2019 and 2020 International Conferences on Integrated Care. The interest and enthusiasm of the participants has caused us to dig even deeper, collaborate more strategically, and expand our dialogue with the wider community of integrated care stakeholders across the globe. Our current focus is to delve into how the COVID-19 crisis is changing the roles of health system managers and leaders and identifying the most emergent skills and competencies for a post-pandemic world.

The leadership and management for integrated systems of care requires new capabilities, ones that challenge the status quo and overcome the institutionalized siloes within professions and within organizations. It requires shifting the way we design, lead and implement health and social care. This leadership imperative predates COVID-19, but the global pandemic has become the tipping point for change.

Does a distinction between leadership and management still make sense? The discussions about the correct definitions and distinctions have occupied researchers and professionals for decades, have fueled management and leadership schools, and covered great volumes of literature – without providing a clear answer. We see the most critical question as simply, how do you motivate people to “do the right things right”? In our research, we acknowledge there is a distinction between the functions of leadership and those of management. Similarly, we stipulate that managers can be leaders, but leaders do not have to be managers. In the end, we have decided that the debate on the distinction is not important, instead we concentrate on the competencies that make for both great managers and leaders in health systems which are increasingly complex, emergent and unpredictable.

Our initial research is shared in two articles that provide frameworks for health system leaders and managers. The first by Evans et al. (2016) highlights the skills and behaviours that facilitate effective leadership of integrated care initiatives, and the second explores the management competencies necessary for integrated care (Miller and Stein 2020). The core tenets of both competency frameworks are mutually reinforcing:

  • the need for systems understanding (macro perspective of strategy),
  • the drive to share leadership and management tasks (distributing power and accountability),
  • the ability to build and maintain relationships with a wide array of partners (building and maintaining trust),
  • the use of collaborative approaches across partners and communities (leveraging the expertise of diverse contributors to co-design change), and
  • shifting from old power to new power (moving away from traditional hierarchies or command and control approaches to decision-making towards more networked and distributed ones).

But many questions remain. Creating integrated systems of health and social care requires representation from many sectors and organizations. How do you democratize leadership across a large group of disparate partners? How do you balance shared leadership with clear lines of accountability? How do you ensure that the sheer number of voices at the table does not make a situation ungovernable? How can groups make effective decisions together? How does work get done, and by whom?

At our most recent workshop, we explored these questions with participants. Together we highlighted a missing piece in our existing competency frameworks – the ability to design and implement clear, effective mechanisms for accountability. In essence, integrated systems of care need to be retooled as continuous learning environments through the use of transparent and meaningful presentation and use of data, with clarity about how these data are used for improvement and change. Leaders and managers working in these systems need to have the right competencies to understand and work with complex information and data, and use them effectively to advance change.

There is no doubt that COVID-19 will have permanent impact at every level of our society and the lessons learned from how we have managed through the pandemic will reverberate for years to come. The level of mobilization at the start of the pandemic was unprecedented, with rapid deployment of technology and innovations, massive shifts in work and workspaces, and significantly truncated cycles for adopting change. But, during the same period we witnessed a regression in leadership approaches, stepping back to more traditional ‘command and control’ styles of leadership and management, which feel more familiar and safer during times of great uncertainty. We are concerned about this dichotomy – progress in how and what we do, but with the loss of progress in how we lead. From our vantage point, we want our research to elevate examples of emergent leadership and management that are successfully addressing the current crisis precisely because of the choices made to work in more collaborative, participatory and connected ways. It is this application of new competencies for leadership and management that will be the focus of our next phase of research.

If you want to share your own experiences, work or reflections on these topics, please get in touch with us. And watch out for upcoming webinars and workshops.


Viktoria Stein
Leiden University Medical Centre
The Netherlands

Robin Miller
University of Birmingham

Jodeme Goldhar
University of Toronto

Anne Wojtak
University of Toronto