By transforming their leadership culture, providers of mental health services can improve the recovery process for patients, say Juliette Alban-Metcalfe and Jennifer Black

Mental health and the impact of mental illness on individuals, families and communities is a key focus for the NHS and associated public services, particularly in a time of diminishing resources and increasingly shared services. Early intervention and the “recovery” approach lie at the heart of most international reform programmes, supported by the growing body of evidence that suggests these are key aspects of success.

There is a need to fundamentally transform the leadership culture of organisations and teams if we are to achieve the innovations and efficiencies that are so badly needed.

‘Leaders need to relinquish some of their “expert” status and work in a coaching and collaborative style’

The term “recovery” refers to a significant shift away from a paternal approach or substitute decision-making model, such that people with a mental illness are encouraged and supported to make their own decisions where possible. Users are educated about illness management and tackling stigma. User-run services are created that offer advocacy, mentoring and peer support.

Research shows that people who understand their health conditions and who are actively involved in decisions about their own care are more likely to value treatment programmes and have better outcomes. When mental health consumers develop a sense of control over their illness and recognise trigger factors and early warning of relapse, they can reduce the likelihood of crisis situations.

A growing number of influential international bodies are advocating the approach, including the Australian government through the imbedding of recovery principles in the national mental health standards, and our own Department of Health.

Moving the culture

It is critical to understand that recovery is not a model but rather a philosophy, an approach and, more importantly, a culture and an attitude. To achieve a change towards a recovery orientation, organisations must move to a system of care delivery which aims to change the course of an illness, rather than focusing on stabilisation and palliation of symptoms. The formality and “expert status” of clinicians must be reduced to enable them to enact a more coaching style.

Services must acknowledge that mental wellbeing is determined by social and psychosocial factors in addition to biological and medical factors. A greater emphasis on protective factors such as housing, employment, socioeconomic status, education and personal relationships, together with a focus on the impact of trauma, stigma and discrimination, are all needed. Stronger, more effective public sector partnership working is essential.

At the same time as there has been a major shift in thinking around approaches to mental health care provision and prevention, the world of leadership thinking has also moved on.

Leadership experts describe the needs of contemporary workplaces as significantly different from the past. In any organisation, there is much greater complexity in structure and work, employees are becoming more demanding of meaning and the ability to express themselves through what they do, interdependencies are rapidly multiplying between and within organisations, and change is more rapid than ever.

‘Engaging leadership is so named because of the significant impact it has on employees’ positive attitudes to work and wellbeing’

These new demands mean yesterday’s leadership approaches just won’t cut it − management, control, protection of power, largely one-way communication or instruction, and the leader as “expert” are no longer effective. Distributed leadership, where everyone in an organisation is encouraged to think for themselves and take responsibility for making quality happen is key, as emphasised by the Francis report.

One of the most interesting, evidenced-based leadership models of recent times is that of “engaging leadership”, developed by Professor Beverly Alimo-Metcalfe. Since her initial publications on the subject in 2001, many more articles and research studies have followed, including one of only a handful of longitudinal studies showing a cause-effect relationship between leadership and productivity that employed objective measures of performance (in this case, government targets for quality of healthcare). This DH research was conducted by Professor Alimo-Metcalfe and her team at Real World Group in partnership with King’s College London.

The key finding of the research, which focused on mental health teams, was that it was only the extent to which the team had an “engaging” culture that differentiated between those that were more successful in meeting government targets than others. What is fascinating about this is how similar an engaging leadership approach is to the recovery approach to mental health care.

Engaging leadership and recovery

As shown in the table below, many of the attributes of an engaging leadership culture are a key part of a recovery approach. There are other factors too, but it is important to note that these findings are not limited to mental health teams − the engaging leadership model has been shown worldwide across sectors to be critical drivers of sustainable effectiveness.

Examples of key characteristics of the engaging team culture in mental health and more widelyExamples of key characteristics of the recovery philosophy
  • Treat the employee as “a whole person”
  • Positive expectations of what the employee can achieve
  • Treat the employee as intelligent human being and an expert in their own context
  • Attend to and enquire about personal aspirations
  • Invite co-creation of a vision of success and how it will be achieved
  • Treat the patient as “a whole person”
  • Positive expectations of what the patient can achieve
  • Treat the patient as intelligent human being and expert in their own context
  • Attend to and enquire about personal aspirations
  • Co-create a vision of success and how it will be achieved

At the time of the team leadership culture research, Professor Alimo-Metcalfe and her team were not aware of the recovery philosophy. In fact, they were only beginning to learn about it when they had concluded the first stage of a follow-on study, sponsored by NHS Yorkshire and Humber, and conducted in partnership between Real World Group and South West Yorkshire Partnership Foundation Trust.

The overarching aim of the study is to identify the key characteristics of effective Community Mental Health teams. The first stage of the study sought to establish, from a consumer, carer, and team leader perspective what success actually looks like.

These data appeared to cluster into five key areas. When these five areas were retrospectively compared with the recovery philosophy, the findings were very strong in their reinforcement of each other.

Team players

The contribution made to team and organisational performance by an engaging leadership approach is by no means limited to cultivating a recovery approach. Rather, engaging leadership is so named because of the significant impact it has on employees’ positive attitudes to work and wellbeing at work − both of which support the emergence of quality outcomes in a clinical and non-clinical setting.

A wealth of evidence suggests an engaging leadership approach, modelled from the top of an organisation, provides the greatest opportunity for maximising potential at individual and collective levels, achieving more with less, innovating, volunteering improvements in how teams and the organisation works, improving safety and customer satisfaction, and being ready and able to handle change. All things the Francis report requires.

‘The treatment the team receives from their leaders will have a strong impact on how they treat other people’

Leaders need to relinquish some of their “expert” status and work in a coaching and collaborative style with individuals. Positional power must be loosened, in spite of the fact that the temptation for both managers and clinicians under pressure is to manage rather than assist and coach the individual to lead.

The culture of the team delivering care will influence the style and culture of care provided to patients and their carers. In turn, the treatment the team receives from their leaders will also have a strong impact on how they treat other people. Senior managers must provide support and encouragement of the approach, rather than assume it can survive, let alone thrive, in isolation of their own style.

Both the recovery philosophy and engaging leadership require that we communicate positive expectations of what is possible. The concurrent rise in awareness and evidence to support recovery and engaging leadership provides an unprecedented opportunity for healthcare organisations to rise to the challenges that face them.

By presenting the business case to others, being passionate and personally committed to ensure your employees are treated with the respect, humanity and support with which you expect them to treat service users, there is no end to what your organisation can achieve.

Barwon Health Mental Health, Drug and Alcohol Services

In Barwon Health MHDAS “engaging leadership” was used as a tool for culture change by developing a highly productive workforce who would be more open and innovative when considering a recovery approach. The executive team realised this path would lead to better outcomes through shared responsibility, achieved via a coaching relationship rather than the historical paternalistic style of mental health service delivery.  

In creating a recovery-oriented workforce, a consultant with a lived experience of mental illness was hired early on to work jointly with psychiatrists, leaders and clinicians to explore the concept of recovery. Each mental health team in the service identified a “champion” to become the recovery mentor who organised an ongoing reflective practice session with the team to explore the concepts and reach their own conclusions about how to progress recovery.

In parallel, the executive team held their own reflective practice sessions to reflect on their leadership of the service, and worked with Real World Group to create a vision and strategy for creating an engaging leadership culture.

Two years on, the service reaps the benefits of open enthusiasm and debate around recovery, with each team working actively on a project to improve the way care is delivered. Assessed employee engagement levels have significantly increased year on year. The highlight has been the demonstration of how sharing responsibility with staff has enabled them to be motivated, creative and innovative in their thinking around recovery.

Juliette Alban-Metcalfe is chief executive at Real World Group and Jennifer Black is a member of the executive team at Barwon Health Mental Health, Drug and Alcohol Services, Australia