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The purpose of this paper is to reflect on the experience of the Advancing Quality Alliance's (AQuA) regional Integrated Care Discovery Community created to translate integrated care theory into practice at scale and to test ways to address the system enablers of integrated care.

Principles of flexibility, agility, credibility and scale influenced Community design. The theoretical framework drew on relevant complexity, learning community and change management theories. Co-designed with stakeholders, the discovery-based Community model incorporated emergent learning from change in complex adaptive environments and focused bespoke support on leadership capability building.

In total, 19 health and social care economies participated. Kotter's eight-step change model proved flexible in conjunction with large-scale change theories. The tension between programme management, learning communities and the emergent nature of change in complex adaptive systems can be harnessed to inject pace and urgency. Mental models and simple rules were helpful in managing participant's desire for a directive approach in the context of a discovery programme.

This is a viewpoint from a regional improvement organisation in North West England.

The Discovery Community was a useful construct through which to rapidly develop multiple integrated health and social care economies. Flexible design and bespoke delivery is crucial in a complex adaptive environment. Capability building needs to be agile enough to meet the emergent needs of a changing workforce. Collaborative leadership has emerged as an area requiring particular attention.

Learning from AQuA's approach may assist others in structuring large-scale integrated care or complex change initiatives.

The purpose of this paper is to describe research that examined physician leadership development using complexity science principles.

Intensive interviewing of 21 participants and document review provided data regarding physician leadership development in health-care organizations using five principles of complexity science (connectivity, interdependence, feedback, exploration-of-the-space-of-possibilities and co-evolution), which were grouped in three areas of inquiry (relationships between agents, patterns of behaviour and enabling functions).

Physician leaders are viewed as critical in the transformation of healthcare and in improving patient outcomes, and yet significant challenges exist that limit their development. Leadership in health care continues to be associated with traditional, linear models, which are incongruent with the behaviour of a complex system, such as health care. Physician leadership development remains a low priority for most health-care organizations, although physicians admit to being limited in their capacity to lead. This research was based on five principles of complexity science and used grounded theory methodology to understand how the behaviours of a complex system can provide data regarding leadership development for physicians. The study demonstrated that there is a strong association between physician leadership and patient outcomes and that organizations play a primary role in supporting the development of physician leaders. Findings indicate that a physician’s relationship with their patient and their capacity for innovation can be extended as catalytic behaviours in a complex system. The findings also identified limiting factors that impact physicians who choose to lead, such as reimbursement models that do not place value on leadership and medical education that provides minimal opportunity for leadership skill development.

This research provides practical applications for physician leadership development and emphasizes that it is incumbent upon physicians and organizations to focus attention on this to achieve improved patient and organizational outcomes.

This study pairing complexity science and physician leadership represents a unique way to view the development of physician leaders within the context of the complex system that is health care.

The needs of complex patients with chronic conditions can be unpredictable and can strain resources. Exploring how tasks vary for different patients, particularly those with complex needs, can yield insights about designing better processes in healthcare. The purpose of this paper is to explore the tasks required to manage complex patients in an anticoagulation therapy context.

The authors analyzed interviews with 55 staff in six anticoagulation clinics using the Systems Engineering Initiative for Patient Safety (SEIPS) work system framework. The authors qualitatively described complex patients and their effects on care delivery.

Data analysis highlighted how identifying complex patients and their effect on tasks and organization, and the interactions between them was important. Managing complex patients required similar tasks as non-complex patients, but with greater frequency or more intensity and several additional tasks. After complex patients and associated patient interaction and care tasks were identified, a work system perspective was applied to explore how such tasks are integrated within clinics and the resulting implications for resource allocation.

The authors present a complex patient management framework to guide workflow design in specialty clinics, to better support high quality, effective, efficient and safe healthcare.

The complex patient framework presented here, based on the SEIPS framework, suggests a more formal and integrated analysis be completed to provide better support for appropriate resource allocation and care coordination.

While theories of complex service systems have advanced important insights about integrated care, less attention has been paid to social dynamics in systems with finite resources. This paper aims to uncover a paradoxical social dynamic undermining the objective of integrated care within an HIV care service system.

Grounded in a hermeneutic analysis of depth interviews with 26 people living with HIV/AIDS (PLWHA) and drawing on Bourdieu’s (1984) theory of capital consumption to unpack dynamics of power, struggle and contestation, the authors introduce the concept of the service labyrinth.

To competently navigate the service labyrinth of HIV care, consumers adopt capital consumption practices. Paradoxically, these practices enhance empowerment at the individual level but contribute to the fragmentation of the HIV care labyrinth at the system level, ultimately undermining integrated care.

This study enhances understanding of integrated care in three ways. First, the metaphor of the service labyrinth can be used to better understand complex care-related service systems. Second, as consumers of care enact capital consumption practices, the authors demonstrate how they do not merely experience but actively shape the care system. Third, fragmentation is expectedly part of the human dynamics in complex service systems. Thus, the authors discuss its implications. Further research should investigate whether a similar paradox undermines integrated care in better resourced systems, acute care systems and systems embedded in other cultural contexts.

Contrasted to provider-centric views of service systems, this study explicates a customer-centric view from the perspective of heterosexual PLWHA.

The purpose of this paper is to describe the design and development of the digital platform for the development and monitoring of care plans for older adults with complex care needs who are users of a home care service.

Case study. The authors conducted an iterative process of design adapted to the environment and user-centred, agile development and research methodologies and a framework of complex interventions. They followed a four-step process: (1) conceptualization: analysis and design; (2) usability and high-fidelity prototyping; (3) software development; and (4) field testing in usual care. Older adults, informal caregivers, professional caregivers, and healthcare and social workers identified specific requirements and participated continuously through interviews, focus groups and consensus.

In the conceptualization phase, the theory, context and requirements were identified, and the content and prototypes were developed. In the usability phase, the design was validated. The approach employed resulted in a digital technology that supports a person-centred care model in a home care company. In the conceptualization phase, the theory, context and requirements were identified, and the content and prototypes were developed. In the usability phase, the design was validated. The approach employed resulted in a digital technology that supports a person-centred care model in a home care company.

The methodology employed has allowed the development of a platform based on theory, user needs and context. This could increase the possibilities of use and implementation of the technology and inspire other developers.

The purpose of this paper is to examine how a complex adaptive systems (CAS) approach can be used to promote the integration of health and social care for the benefit of the user.

This paper is a research review and a conceptual analysis of key issues identified in the growing literature on CAS. An application of the CAS approach to the field of integrated care is presented. The paper identifies crucial issues, notably: bringing together different providers and the place of the user as a co‐producer of care.

The benefits of the CAS approach to integrated care are distilled. Above all CAS provides managers of health and social care with an alternative mindset. Guiding principles are offered to these managers to facilitate development towards a more integrated system of health and social care. The possibility to benefit from the user's own resources is increased when organizations are viewed from a CAS perspective. CAS promotes emergent ways of working.

The CAS approach makes possible a significant improvement in relationships between providers and users and managers and providers; a possibility of more productive relationships and better care outcomes, not least in terms of user satisfaction.

The paper shows that CAS literature applied to the health and social care field points the way for managers to rethink the functioning of the field, specifically to go beyond the present dominant but outdated machine model to one which encourages the cooperation of providers and users for better outcomes.

People with complex health conditions must often navigate landscapes of uncoordinated public, private and voluntary health-care providers to obtain the care they need. Complex health conditions frequently transcend the scope of typical health-care service systems. The purpose of this paper is to explore and characterize such unique assemblages of actors and services as “user-defined ecosystems”.

Building on literature on customer ecosystems, this paper introduces the concept of the user-defined ecosystem (UDE). Using an abductive approach, the authors apply the concept in an interpretive, qualitative study of ten families with special needs children.

This study uncovers complex UDEs, where families actively combine a broad range of services. These ecosystems are unique for each family and extend beyond the scope of designed service ecosystems. Thus, the families are forced to assume an active, coordinating role.

This paper shows how to identify ecosystems from the user’s point of view, based on the selected user unit (such as a family) and the focal value-creating function of the ecosystem for the user.

This paper highlights how service providers can support and adapt to UDEs and, thus, contribute to user value and well-being. This can be used to understand users’ perspectives on service and systems in health and social care.

This study develops the concept of the UDE, which represents a customer-focused perspective on actor ecosystems and contrasts it with a provider-focused and a distributed perspective on ecosystems. This study demonstrates the practical usefulness of the conceptualization and provides a foundation for further research on the user’s perspective on ecosystems.

Person-centred care is a fundamental component of any service. This case study aims to explore the delivery of person-centred care in the voluntary sector, discussing how integrating support can be achieved to benefit individuals. It identifies challenges, best practice and learning that can be applied across sectors and promotes further enquiry.

This case study is the result of a service audit at a mental health charity. The findings are a blend of reflections, observations and examples from service delivery, synthesised with national policy to provide evidence of best practice and processes that enable person-centred care.

A focus on need not diagnosis, creating accessible and inclusive services, employing dual trained practitioners, having a varied skill mix along with holistic self-assessment tools are all enablers for integrated person-centred support. Multi-agency assessment frameworks, collaboration across services, cross-agency supervision and a shared vision for integration and person-centred care support services to coordinate more effectively. Barriers to integrated person-centred support include complex physical and mental health needs and harmful risk and safeguarding. The diversity of the voluntary sector, a lack of resources along with complex and competitive funding also hinder integration.

This case study provides a valuable insight into the voluntary sector and shares its findings to enhance best practice. It aims to promote interest and invites further research into health and social care delivery by the voluntary sector. As this delivery continues to increase, it is vital to examine the interface between the voluntary and statutory sector. Through better understanding and further research across all sectors, the author can identify how they can achieve person-centred outcomes and deliver the national policies.

The authors aim to present findings from their research on the implementation of Unified Assessment (UA) policy and the work of care coordinators who oversee the delivery of support to older people with complex needs.

A mixed methods approach included staff interviews (n=95) and focus groups (n=3).

The care coordinator role is controversial and the lack of common terminology across health and social care obscures its importance. It is seen as a social care responsibility. Limited ownership amongst healthcare professionals leads to tensions in practice. The challenges of breaking down silo thinking embedded in established professional practices are highlighted as are infrastructural and capacity deficits. Disparities between policy intentions and practice means that UA is failing to meet core objectives relating to the delivery of seamless support.

Further research is needed to develop and evaluate evidence‐informed interventions that test solutions to the problems faced in practice and support the delivery of more effective arrangements.

Practice development may be supported by: guidelines that are more prescriptive and include a formal role definition; joint training to promote shared understanding of key concepts; investment in administrative and IT infrastructures; and more coordinated direction at strategic level.

Over a decade has elapsed since the publication of UA Policy Guidance; however, there is limited published evidence on the effectiveness of UA policy and its translation into practice.

The purpose of this paper is to contribute to knowledge by exploring and distilling how providers in health and social care who have adopted complex adaptive systems thinking (CAS thinking) and have a collaborative mindset are in a better position to achieve integrated care than those who adopt reductionist approaches.

This paper is a research review and a conceptual analysis of key aspects drawn from the literature on CAS thinking and collaborative mindset applied to integrated care. By choosing this approach the authors intend to promote understanding and efforts made to put it into action. The intended audience comprises managers responsible for addressing the problem of fragmentation and the research community challenged by the task of supporting those managers.

Specialization of knowledge and skill has increased the risk of fragmentation. It is possible to reduce that risk and hence to foster integrated care when providers with different specializations stimulated by a collaborative mindset develop an understanding of how they connect with others in a CAS. The essence of CAS thinking applied to integrated care is the readiness to connect. This readiness is facilitated by adopting a collaborative mindset.

Literature on CAS thinking and collaborative mindset have evolved independently of one another. The study points at the importance of connecting the two concepts to produce effective action.