The evaluation of a local whole systems intervention for improved team working and leadership in mental health services

Fourteen mental health teams covering community, inpatient, and primary care across different NHS regions in England completed the pilot stage of the evaluation of a seven-day focused local whole systems intervention for improved teamworking and leadership. Outcome at the end of the programme was evaluated using measures of teamwork, team effectiveness, staff burnout, job satisfaction and leadership style. Team working improved significantly across the sample in terms of communication, support for innovation, clarity of objectives and focus on quality. Although changes were in the desired direction for all the other outcome measures they did not reach statistical significance. Exploring changes for teams as a whole, perceptions of team working improved from the start to the finish of the programme in 13 teams. Participant feedback from session to session of the programme was positive. Action learning sets, user involvement, improved communication and small group discussions were particularly well received. Ratings of the delivery of the programme were also high across all 14 programmes. The study provides pointers for the development of whole systems interventions in this key area of local service improvement. The Innovation Journal: The Public Sector Innovation Journal, Volume 14(1), 2009, article 6. 2 The evaluation of a local whole systems intervention for improved teamworking and leadership in mental health services Introduction It seems widely acknowledged that in light of an “ever-tightening financial situation.. more will have to be achieved through service redesign rather than increased capacity” (McLellan, 2005, p.3). Since the turn of the century there has been dedicated improvement support to achieve such redesign in mental health services, for example through the National Institute for Mental Health in England (NIMHE). Much has been achieved through improvement work aimed at improving the process and experience of care (as required by standard five of the National Service Framework for Mental Health; Department of Health, 1999), and multiple sources of support for leadership development. However, despite an explosion of publications on leadership “...so far, 40 years of NHS management training has not done much to improve service delivery” (Millward & Bryan, 2005, xx). There is a complex and often poorly coordinated market of leadership development support for practitioners to navigate (Millward & Bryan, 2005; Edmonstone & Western, 2002). Reviews of the leadership literature increasingly conceptualise leadership as an emergent process that occurs in the productive quest for specific outcomes; “a process whereby an individual influences a group of individuals to achieve a common goal” (Northouse, 2004, p.3). This dispersed model of leadership is also endorsed by policy, for example in the Darzi review (Department of Health, 2008) of the English National Health Service (NHS) with its expectation that ever practitioner will be a clinician, partner and leader.. Dispersed formulations of leadership need to be mirrored in leadership development initiatives. In the early days of the NHS Leadership Centre, Goodwin (2000) advocated a move away from a focus on individual skill development towards a “local leadership mindset”. He advocated that leadership development should be mandatory, locally focussed, based around actionlearning principles, and concentrated on inter-organisational and shared leadership between organisations rather than leaderfollower relationships within organisations. Despite the complex and diverse market of improvement resources, development support that integrates improvement science and leadership development through dedicated local whole systems interventions remains unusual. Similarly while there exists widespread recognition of the dispersed nature of leadership within complex health and social care systems (e.g. Bolden, 2004) the essential team-based nature of provision is comparatively rarely recognised in improvement interventions. This is particularly problematic in light of the consistent finding of the Healthcare Commission’s (2008) NHS National Staff Survey on teamworking. The latest revealed that 93% of staff responded positively when asked: “Do you work in a team?” but that this shrunk to only 42% when the survey explored whether the team in question fulfilled criteria for a well structured team: clear objectives, close working with other team members to achieve these objectives, regular meetings to discuss effectiveness and how it could be improved, and no more than 15 members. These findings have been consistent every year since 2003 and are of considerable import given findings that “pseudo” teams that are teams in name alone achieve outcomes that are often worse than not working in a team at all (West & Spendlove, 2005). The Innovation Journal: The Public Sector Innovation Journal, Volume 14(1), 2009, article 6. 3 With funding from the Leadership Centre (part of the then Modernisation Agency) two of the authors (SO & CB) developed the “Effective team working and leadership in mental health” (ETL) programme. Its development was influenced by some key observations: 1. Leadership initiatives sometime fail to focus strongly enough on service improvement and service improvement initiatives often fail to take enough account of the involvement of senior managers (Onyett, 2006). Hence the need to integrate the two at local level. The programme included exposure to the Modernisation Agency’s most widely used approaches to improvement such as process mapping and plan-do-study-act cycles that have a recognised evidence-base (McLeod, 2005; McNulty & Ferlie, 2002). 2. Leadership is bound by context, shaped by the task in hand and dispersed (Bolden, 2004). Effective leadership can only be judged by results. In other words successful leadership is about creating an environment that supports individual team members in being maximally effective in achieving those outcomes that are valued by users and their supporters. Creating that environment is the job of everyone in the team, although key individuals will have particularly roles in achieving, maintaining and improving the environment over time. Issues of leadership were therefore explored with all participants rather than just those in formal leadership roles. 3. The vast majority of care is delivered by teams and this is where service improvement and effective leadership needs to be enacted (Healthcare Commission, 2008). The programme development was informed by findings on the effectiveness of health care teams (Borrill et al, 2000) and a review of leadership and team working in mental health (Onyett, 2003, 2007). It is not surprising, though rarely acknowledged, that factors underpinning effective leadership and management (Alimo-Metcalfe and Alban Metcalfe, 2005) coincides strongly with those associated with effective team working and innovation (West et al, 1998; Borrill et al, 2000). 4. It cannot be assumed that the ways teams are currently configured are real teams in the sense that they are the people who most need to work together to achieve improvement for a specific group of service users. The programme was therefore designed for a maximum of 21 participants who were interdependent on each other to achieve positive outcomes for a specific group of service users. Such interdependence is a key criteria for effective teamworking (Onyett et al, 2007). 5. In trying to engage practitioners in change it makes sense to use evidence-based models of change that they are familiar with from their clinical work. For example it used a solutions focussed approach to clarify objectives (Jackson and McKergow, 2002) and motivational interviewing to engage the involvement of stakeholders (Rollnick, 1999). 6. Sustainable teamworking and improvement requires that we also consider the mental health of staff, and so this was the focus of the final day of the programme. The Innovation Journal: The Public Sector Innovation Journal, Volume 14(1), 2009, article 6. 4 Table 1. Outline contents of the ETL programme. Day one q Listening to users and their supports give their account of what it is like to experience local services. q Developing a shared vision of an effective local service. q Hearing managers and strategists talk about the role of local teams and their inter-relationships. q Exploring leadership both as a leader and a follower. Day two q Describing, clarifying and agreeing the values that underpin the work of the teams. q Evaluating team climate, and using this to inform the team’s development needs. q Individual planning of change projects. Day three q Understanding each other’s roles more clearly. q Learning how to support each other more effectively through peer coaching. q Supported selfreflection on participant’s roles as leaders and team members. Day four q Understanding the complex systems in which participants work and how to achieve meaningful and sustained improvement. This includes exploring some widely used tools for improvement, such as process redesign, plan-do-study-act cycles and outcome measurement. Day five q Improving communication in the team by reviewing the effectiveness of meetings, how information is exchanged and how participation in decision-making can be increased. Day six q Clarifying issues of responsibility and accountability within the team and how decisions are made. This includes participants getting to grips with difficult issues concerning the exercise of power within teams, and their own authority. Day seven q Exploring how the team can continue to improve over the long term, including a focus on maintaining the mental health of team members. The programme was delivered over seven days with the first two days close together and the others spaced out over three week intervals. Research on teams (e.g. Borrill et al, 2000) highlights that clarity of objectives is the sine qua non of effective team working. The initial days therefore focused on clarifying the aims and values of the service by getting both a strategic view from senior managers, and service users and their supports (e.g. friends and family) telling stories of their lived experience of the service as it is. From day three participants spent the afternoons in action learning sets pursuing agreed personal objectives informed by the earlier objective setting work. Participants received considerable preparation on how to work effectively in learning sets. The programme was configured to contain both core and optional components, to be included depending on needs as defined by participants in the early stages of the programme and in pre-programme planning with senior managers. A full outline of the programme is given in Table 1. The Leadership Centre funded regional coordinator posts within NIMHE development centres, a trainthe-trainers process and support for implementation. In this pilot phase it was implemented in services for adults and older adults with mental health problems, prison inreach and prison staff, low secure provision, local implementation teams and zero-rated trusts The Innovation Journal: The Public Sector Innovation Journal, Volume 14(1), 2009, article 6. 5 through the Clinical Governance Support Team. The Leadership Centre adapted the programme for implementation in cancer services and ambulance trusts. It has subsequently been rolled out through NIMHE (now within the Care Services Improvement Partnership; CSIP) development centres with interest expressed in expanding it to other care groups (e.g. in-patient care, children and family services, early intervention, and learning difficulties) and to executive teams.