Delegation within Integrated Care Systems: What might aid practice and process?

Ruth Abrams is an organisational psychologist and lecturer in health services research, whose research interests are workforce experiences of organisation, workflow, and service delivery within the healthcare sector. Her work includes research on role boundaries among homecare workers, work delegation within primary care, and multidisciplinary teamwork in healthcare settings.

Carin Magnusson is a lecturer in health services research, whose research interests are healthcare organisation and culture, including training, student retention, and professional preparation. Her particular interests are in patient safety and issues of governance and accountability across healthcare organisations.

Karen Stenner is a lecturer in health services research, whose research interests include the evaluation of extended roles in medicines optimisation and non-medical prescribing. Karen has published widely on the impact and implementation of prescribing by nurses and other healthcare professionals, with a focus on long-term conditions.

A key aim of the NHS Long Term Plan is to integrate services across sectors, helping them to form strategic partnerships in order to facilitate a pooling of resources at localised levels. However, the NHS has been facing a significant workforce crisis over the last few years, while simultaneously seeing a rise in demand for services.

New models of care are intended to address the workforce crisis, patient access to healthcare, and reduce the burden on wider services across both primary and secondary care.1

Delegation is a highly complex skill … Context matters here, as what works well in one setting may not translate directly to another setting

This is giving rise to innovative ways of working and organising health care, particularly within the community and at the workforce level. On a day-to-day basis, this work requires networks of multidisciplinary teams operating collaboratively, rather than in competition.

These new ways of working often involve task shifting, sharing, and delegation between multidisciplinary team members.

Delegation is the transfer of responsibility for the performance of an activity from one individual to another.2 As a highly complex skill, delegation requires sophisticated clinical judgement. For delegation to work well, attention is required at both an organisational and professional level.

This involves reflection on: organisation culture and resource availability; professional identities; systems capable of encouraging collaboration and communication; professional autonomy; risk tolerance; role expectation; and receptiveness towards giving and receiving delegated workloads.1

Presently, the range of nomenclature for both new services and new roles, the potential for professional resistance, and a lack of clarity regarding specific responsibilities may make clear delegation processes within integrated care systems very difficult to achieve.

This mixture can provide fertile ground for problems with time management, productivity, communication, and teamwork.

Effective interventions and service evaluations need to be built into emerging integrated care systems and new ways of working, in order to better explore the practice and process of delegation and multidisciplinary working.

Supporting the workforce to get clarity on delegation and workflow is an area ripe for innovative solutions

Context matters here, as what works well in one setting may not translate directly to another setting. For example, programmes to enable delegation to non-registered healthcare workers of insulin injections3 have been in operation for over 10 years in some community trusts,4 whereas others have struggled to gain momentum. Therefore, implementation of any intervention intended to address and support delegation processes will also require careful evaluation.

Planned interventions and evaluations specifically looking at delegation processes within the community may be capable of pointing out the ways in which care provision across the country is navigated by frontline workers by indicating both gaps and best practice.

Supporting the workforce to get clarity on delegation and workflow is an area ripe for innovative solutions. A tentative development is the implementation potential of e-job planning; software designed to support the documentation and digitalisation of professional activity. However, e-job planning software coverage and usage in healthcare settings is not used by 73% of trusts.5

Other solutions may include addressing the more interpersonal processes of delegation. For example, a combination of organisational support and educational interventions may help to develop effective delegation skills and trust. This may include providing space for reflexive and supportive conversations within teams.

These interventions and evaluations need to consider the perspectives of frontline staff and management, as well as offer periods of activity and reflection.



The authors would like to thank Kamal R Mahtani for his comments on an earlier draft.



1. Abrams R, Wong G, Mahtani KR, et al. Delegating home visits in general practice: a realist review on the impact on GP workload and patient care. Br J Gen Pract 2020; DOI:
2. Barrow JM, Sharma S. Five Rights of Nursing Delegation. Treasure Island, FL: StatPearls Publishing, 2019.
3. Diabetes UK. How to: manage insulin administration in the community. Diabetes UK, 2016.
4. Cook A. Insulin administration by non-registered practitioners. Journal of Diabetes Nursing 2015; 19(6): 233–237.
5. NHS England, NHS Improvement. E-job planning the clinical workforce: levels of attainment and meaningful use standards. 2019. (accessed 16 Sep 2020).


Featured photo by Randy Fath on Unsplash

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