1.6 Analyse how integrated working with other agencies delivers better outcomes for individuals and the role of systems leadership within this

This guide will help you answer 1.6 Analyse how integrated working with other agencies delivers better outcomes for individuals and the role of systems leadership within this.

Integrated working means that different agencies—such as health, social care, housing, education, and the voluntary sector—work together as a single team to deliver support. Rather than operating in isolation, these agencies share information, plan together, and provide joined-up services. This approach is increasingly seen as the best way to deliver high-quality, person-centred outcomes in adult care. Systems leadership is the style of leadership needed to guide and sustain this way of working.

What Is Integrated Working?

Integrated working brings together professionals and organisations across boundaries, creating a seamless experience for individuals who use services. It can include:

• Multi-Disciplinary Teams (MDTs), where staff from different backgrounds plan and deliver care together
• Shared care plans and records
• Joint assessments and reviews
• Coordinated referrals and transitions between services
• Pooled budgets or resources

This joined approach focuses on the holistic needs of the individual, rather than the isolated aims of each agency.

Benefits of Integrated Working for Individuals

Integrated working leads to better outcomes because it:

Provides Holistic, Person-Centred Support

Integrated working treats individuals as whole people, not as a collection of separate needs. Social, medical, housing, and emotional needs are all considered. This means:

• Fewer gaps or overlaps in care
• More relevant and effective support plans
• Higher satisfaction and improved wellbeing

Improves Continuity and Simplicity

When agencies align their work, individuals benefit from:

• Fewer assessments and having to repeat their story multiple times
• Smoother handovers between services (e.g., hospital discharge to home care)
• More consistent communication and follow-up
• Less confusion about who is responsible for what

This reduces stress and makes it easier for individuals to navigate the system.

Early Intervention and Prevention

By sharing information and concerns, integrated teams can:

• Spot problems or risks earlier—before they become serious
• Put preventive support in place quickly
• Reduce hospital admissions or emergency interventions

This leads to more stable, independent lives and reduces crises.

Improved Access to Services

Integrated working removes barriers between services, meaning:

• People get the help they need more quickly
• Services can be tailored and adjusted as needs change
• Better communication between all professionals involved

Individuals are less likely to “fall through the cracks.”

Empowerment and Choice

Individuals and their families become active partners in care planning. Their voices are heard in meetings, and care plans reflect their goals. Professionals from different services listen together and respond to the things that matter most to the person.

More Efficient Use of Resources

Integrated working makes better use of time, staff, and money. There is less duplication, and services are designed around what works best for people rather than organisational convenience.

Systems Leadership

Systems leadership is about leading beyond the boundaries of a single organisation. It is needed because integrated working involves multiple partners with different priorities, structures, and cultures.

Key features of systems leadership include:

• Seeing the “big picture” of health and social care in a community
• Bringing people together around shared goals, not just individual agency targets
• Building trust across different teams and organisations
• Creating a shared vision for what good looks like
• Working through complexity and ambiguity without clear lines of command
• Encouraging open communication and learning

Systems leaders focus on outcomes for individuals, not just the needs of their own service.

The Role of Systems Leadership in Integrated Working

Systems leadership makes integrated working possible by:

Building Collaboration and Trust

Systems leaders break down silos and encourage openness. They:

• Foster relationships across different professions and organisations
• Support joint training and development
• Encourage honest discussions about strengths, gaps, and challenges

This lays the groundwork for genuine partnership working.

Creating Shared Accountability

By setting shared goals and outcomes, systems leaders ensure that everyone owns the results, not just one agency. They:

• Develop shared care plans and outcome measures
• Hold regular joint meetings or reviews
• Make sure everyone knows their contribution is valued

Sponsoring Innovation

Systems leaders are willing to adapt and try new ways of working, such as:

• Piloting new joint services or processes
• Testing digital record sharing
• Responding flexibly to local needs

They learn from successes and setbacks and spread good practice across the system.

Overcoming Barriers

Integrated working can face problems such as:

• Different IT systems and paperwork
• Complex funding models
• Resistance to change
• Conflicting priorities

Systems leaders help solve these problems by negotiating, advocating for joined-up solutions, and keeping everyone focused on the person at the centre.

Encouraging Co-Production

Systems leaders bring individuals and their families into the heart of planning, service design, and review. This ensures that professionals and individuals work as equal partners.

Examples of Integrated Working and the Impact

• An MDT involving GPs, social workers, district nurses, housing officers, and voluntary groups meets weekly to discuss people with complex needs. Outcomes include better management of long-term conditions, fewer unplanned hospital admissions, and increased independence.
• A shared care coordinator supports people through transitions from hospital to home, working with health, care, and community services. The person has one point of contact, clearer communication, and quicker access to support.
• Local authorities, NHS, and charities jointly run a falls prevention programme, reducing injuries and improving quality of life for older people.

In these cases, individuals experience support that feels personal, joined-up, and effective.

Monitoring and Reviewing Outcomes

Effective integrated working is reviewed regularly to check whether it is delivering for individuals. This includes:

• Collecting feedback from individuals, families, and staff
• Reviewing joint care plans
• Looking at data on hospital admissions, readmissions, and quality of life measures
• Making changes together as needed

Systems leaders oversee this process and keep everyone focused on continuous improvement.

Final Thoughts

Integrated working delivers better outcomes for individuals by creating joined-up, person-centred support that addresses all areas of life. Systems leadership is critical for making this happen, breaking down barriers between organisations, and keeping everyone working towards shared goals. Through this leadership, integrated working becomes more than a policy—it becomes a reality, bringing meaningful, lasting benefits to people who use adult care services.