Discussion

An ‘enhanced foundation’ of the 2022 AHP Strategy for England5 is the promotion of diverse and inclusive leadership of AHPs within executive boards and senior teams, along with the removal of practices that ‘prevent AHPs from harnessing their leadership ability’. The importance of effective clinical leadership cannot be underestimated. A lack of effective clinical leadership has been seen as a contributing factor in incidents of poor-quality care and adverse outcomes.37 38 While investment in leadership is considered to promote innovation, collaboration, improved care and better use of resources.19

In 2018, NHS England recommended that strategic AHP leaders were appointed within provider organisations,1 and more recently, within integrated care systems.39 The aim is to provide the AHP workforce with greater visibility and voice and to ensure that the workforce can contribute to system-wide policies and initiatives.39 However, the diversity of the allied health professions means that each group might need its own representatives to ensure the priorities and needs of each group are heard, and their individual contributions to Trust/HBs priorities are not overlooked.

The results of this study confirm that there is an inequity of representation of the allied health professions within senior AHP leadership. It was found that physiotherapists (who account for 25% of registered AHPs40) occupy 46% of the Chief AHP roles occupied by AHPs and occupational therapists (who account for 17% of registered AHPs40) occupy 24%. Therefore, with 70% of the AHPs in chief AHP (or equivalent) roles being from either a physiotherapy or occupational therapy background, questions must be asked regarding why clinicians from other allied health professions are not being represented within these leadership positions.

Further, seven of the allied health professions were not represented at all, our results show that the professions with the smallest workforces (those with under 5000 registrants) are not currently represented. These include drama therapists, music therapists, prosthetists and orthotists, orthoptists and osteopaths.40 However, it is not quite as straightforward as just the size of the workforce being the reason for the lack of representation. For example, the AHP profession with the third largest workforce is radiography with a very similar number of registrants compared with occupational therapy. However, just two chief AHP roles are currently held by radiographers while 26 are held by occupational therapists. Conversely, dietitians have a workforce of just over 10 000 registrants but currently hold 10 chief AHP roles while operating department practitioners have a workforce of 15 000 but are not represented within chief AHP roles.

The results from this study show that not all AHP professions were employed by all the Trusts/HBs who responded. We found that dietitians, occupational therapists, physiotherapists and speech and language therapists were employed by the most Trusts/HBs and it is these four professions which were also found to occupy the four highest numbers of chief AHP roles. Likewise, prosthetists and orthotists, music therapists, drama therapists and osteopaths were among those employed by the least numbers of Trusts/HBs. In the instances where the chief AHP role has been filled by a member of a profession with a small workforce that is, art therapist, three of the four Trusts/HBs who responded were specialist Trusts/HBs (ie, they specialise in a specific condition such as cancer or neurology). Anecdotally, based on the authors’ experiences, in some Trusts/HBs, due to workforce shortages, sometimes AHPs are used to cover service provision typically provided by a different allied health profession (eg, a specialist podiatrist prescribing ankle foot orthoses which would typically be provided by an orthotist). While there are instances where this might be acceptable, further forward referrals should be organised either to multidisciplinary teams or specialist services for the benefit of the patient. This seldom happens and appropriate AHP leadership would have the potential to change this dynamic.

The combination of being both part of a smaller workforce and not being employed by the majority of Trusts/HBs may mean there is less familiarity with and understanding of these allied health professions among senior management, other clinical teams within the Trust/HB, and patients. Potentially resulting in those professions being less well integrated within the hospital structures, creating a potential barrier to those in the professions with smaller workforces reaching senior leadership roles. This is exacerbated in the case of some professions (such as prosthetists and orthotists) which are often contracted services meaning that their workers are not direct employees of the Trust/HB.41 There is also the potential that unfamiliarity is a reason that these smaller workforces are employed by fewer Trusts/HBs. In a survey investigating occupational therapists’ contributions to palliative care, it was noted that when colleagues had an increased understanding of what an occupational therapist can contribute, it led to occupational therapists expanding their scope of practice.42 Raising the profile of AHP skillsets may lead to their specialisms being used in a wider scope of healthcare environments.

The presence of AHPs within senior leadership roles increases the visibility of the AHP professions and provides credibility with Trust/HB boards, as well as demonstrating that those professions are valued43 and considered able to contribute to service redesign and improvements. The results of this study found that 19% of the Trusts/HBs who responded do not currently have a Chief AHP or equivalent role, and 80% of those did not envisage creating one within the next 6 months. Regarding job titles for AHP leads, in 2018 it was reported that there were 41 job titles across 43 job descriptions for the most senior AHP lead44; meaning that largely no ‘readily identifiable ‘go-to’ AHP leader’ existed within the NHS, as there is for other professions such as nursing. The current study identified 50 different job titles for equivalents of chief AHP roles, indicating that standardisation of this title is still an issue.

A lack of visible role models within senior leadership contributes to a reduced sense of identity and leaves AHPs without a readily identifiable leader as exists for other professions (eg, the director of nursing).43 45 The absence of professions with smaller workforces in these roles creates a continuing problem with culture and a perception that leadership opportunities are not open to them45 46 which in turn contributes to the absence itself. Leader inclusion is shown to be effective in facilitating an inclusive work environment, increasing positive employee attitudes and enhancing performance.33

A further complication is the lack of clarity regarding which professions are classified as AHPs. There are significant differences between the four nations of the UK, with some professions only having been recently added to the list. Even within England, some Trusts will include more than the 14 professions recognised by NHS England,6 such as psychologists, psychotherapists, biomedical scientists and social workers.44 This is also true internationally, with the USA and Australia including a wider range of professions.47 Furthermore, the term ‘therapies’ is often used as a synonym for AHPs which creates yet more confusion.48 49 As there is no universally accepted definition for the allied health professions, this impacts further on the sense of identity of AHPs, in particular, those from the professions with smaller workforces, and also the understanding of their roles and the contribution they can make within healthcare systems.

Another possible barrier for the smaller AHP professions being appointed to senior leadership positions is that those in these professions are less likely to have received leadership training during their career than the AHP professions with larger workforces, who, in turn, are less likely to have received training than nurses or medics.45 This is partly because as a collection of diverse professions, AHPs work in a variety of different settings and have less defined career pathways when compared with medical and nursing professions.14 46 A degree of serendipity has been reported in the career paths of those who have reached senior leadership positions, with knowledge having been acquired in ‘unstructured opportunities’45 due to a lack of developmental leadership roles being available for AHPs.14

As a result, AHPs (particularly those from professions with smaller workforces) can feel inadequately prepared or qualified for leadership positions38 50 with a lack of a clear structure to support leadership development.51 With the different career structures come significant variations in opportunities to develop leadership and management skills.31 For example, AHPs are usually employed in direct patient care roles, with fewer opportunities to progress into non-clinical areas.38 While in the current study occupational therapists occupied nearly a quarter of the chief AHP (or equivalent) roles, Eva and Morgan42 found occupational therapists across Europe spent their time on direct and indirect patient care activities, with limited ability to participate in leadership activities, and this will be true for other AHP groups. Traditional AHP career pathways tend to focus on the development of clinical skills, research or specialisation which may ‘reduce opportunities for operational and strategic leadership’.14

AHPs can find fewer career progression opportunities open to them; a recent NHS report noted that access to developmental leadership roles tends to be restricted to nursing or medical professions.14 Further, some posts are open to applicants from certain professions only, either excluding some AHP groups or not being open to AHPs at all.28 44 When chief AHP posts are open to AHPs, some Trusts have reported issues with not being able to appoint candidates due to gaps in their skills, knowledge and experience.14 Wylie and Gallagher52 found that AHPs who had received leadership training exhibited more transformational behaviours than those who had received none, meaning that they are more likely to possess the skills needed to contribute to healthcare planning and service delivery. Overall, it is recognised that leadership development within the NHS is ‘uncoordinated and inconsistent’.45 For AHPs, it has been recommended that leadership roles should be promoted as part of (rather than alternatives to) clinical progression and that training opportunities should be available for AHPs earlier in their careers, even in preregistration education.14 22 This would provide reassurance to AHPs that moving into leadership positions would not be a threat to their values or clinical credibility36 46 as these moves would be established and normalised steps in their career pathways, just as they now are for professions such as nursing. The NHS now provides opportunities open to AHPs to develop their leadership skills.53 54

Results found that 86% of those in Chief AHP (or equivalent) roles did not have a position on the Trust/HBs executive board. Of the nine chief AHPs (or equivalent) roles who had both an AHP background and a position on the Trust executive board, six were from Welsh HBs, which is due to the requirement in Wales to include an officer responsible for therapies and health sciences on executive boards.30 This shows that a change in NHS policy regarding which positions must be included on the board does have a positive impact on the inclusion of AHP leadership positions. Reducing constraints on AHPs to develop and demonstrate their senior leadership potential.31

As there are few chief AHPs (or equivalent) roles with a place on a Trust/HB executive board, responsibility for AHPs generally lies with the director of nursing or chief nurse.20 However, those from a nursing background may be unable to adequately represent AHPs at the executive board level, partly due to the extent of the nursing agenda,44 and partly because they are unlikely to have an in-depth understanding of the scope of practice for each of the of professions classified as AHPs. This is also due to the diversity across various AHPs and the marked differences between them. The chief AHP role can provide the necessary knowledge, reduce the fragmentation, and bring the workforce together,28 but this would be even more effective if all the Chief AHPs had a place at the executive board level.

NHS England has raised the profile of AHPs in recent years, ensuring that the term ‘AHP’ has a position and purpose within the clinical workforce of the NHS. However, as all the allied health professions are not represented in the most senior roles, it introduces the risk that the term ‘AHP’ will become synonymous with the professions with the largest workforces.