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Abstract
Background NHS England’s Chief Allied Health Profession’s Officer has called for investment in allied health professions (AHPs) leaders and the need to address limited leadership development opportunities for AHPs. We report the evaluation of a small-scale leadership initiative in a UK National Health Service (NHS) provider where part-time, fixed term, project focused AHP leadership fellow posts were established.
Aim To gain insights about the implementation and benefits of an AHP leadership fellow initiative and to identify learning to inform future AHP leadership development.
Method A participatory evaluative approach was adopted, involving the associate director for AHPs who established the initiative and the first cohort of AHP leadership fellows.
Findings There is evidence of organisational value and benefits for AHP leadership fellows which map to mid-career leadership opportunities described in NHS guidance.
Conclusion AHP leadership fellow posts provide innovative experiential opportunities for authentic and meaningful strategic leadership development consistent with NHS guidance. While small scale, with limited representation from just two of the AHPs recognised in the NHS, there are indications of positive outcomes for both aspiring AHP leaders and employers. The approach could be replicated across healthcare systems, in different settings and with wider representation from other AHPs.
- development
- career development
- learning
- multi-professional
- sucession planning
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Introduction
There is evidence of a relationship between allied health professions (AHPs) engagement with service improvement and senior AHP leadership at or close to board level.1 Leadership structures and seniority vary across the National Health Service (NHS) but where senior AHP leadership posts are established, board level leaders recognise their value,2 while simultaneously acknowledging a paucity of AHP leadership development opportunities. Guidance for clinicians and trust boards3 identifies key leadership development factors and prompts a more robust approach to AHP leadership and development. AHPs report leadership development barriers4 and there is under-representation of AHPs in senior leadership positions, particularly from smaller professional groups.5 The lack of visible AHP board level leaders reportedly limits AHP leadership career aspirations.6
Little is known about how NHS trusts are developing AHP leaders or the impact of such development. This evaluation provides insights about a small-scale AHP leadership development initiative conducted during 2020 at West London NHS Trust (WLT). This NHS provider delivers mental health, community physical health and specially commissioned services for approximately 800 000 people and employs around 4500 staff, of which around 300 are AHPs.
Method
A four-stage participatory evaluation was conducted7 between Autumn 2022 and Spring 2023:
Scope: inception and project planning by associate director for AHPs (ADAHP) and academic partner (AP) to identify data sources, participants and gain employer and ethical approval.
Discover: collection of documentary, interview and survey data from ADAHP and three from four of the first cohort of AHP leadership fellows.
Interpret: data analysis by AP identifying broad themes; sharing and refining of themes to agree findings with all participants in an Outcomes Workshop.
Recommend: production of evaluation report for WLT including findings and recommendations informed by Outcomes Workshop.
In a small-scale participatory evaluation, data saturation is not anticipated. Using data from the Discover phase, tentative themes were identified by the AP, adopting a proportionate approach in which ‘a theme is a meaningful, recurring pattern that researchers first develop from the data, and then use to interpret that data for an audience’ (p2).8 Themes were reviewed and refined by participants in the Outcomes Workshop to produce agreed findings.
The project met Health Research Authority9 evaluation criteria and was registered with the WLT Audit Committee. Standards for Quality Improvement Reporting Excellence guidelines were used.10
Findings
Findings agreed by participants in the Interpret phase Outcomes Workshop of the participatory evaluation are reported as:
Design and delivery.
Value for aspiring AHP leaders.
Organisational value.
Learning for future leadership fellowships.
Design and delivery
The absence of a designated deputy prompted the ADAHP to create project-focused, part-time leadership fellow posts thus releasing her to take up a short-term NHS arm’s length body leadership development secondment. The aim was to provide project-based, strategic leadership stretch for aspiring AHP leaders.
Working with human resource colleagues, a job description, person specification and fair recruitment process were agreed. Four part-time, 6-month fixed term leadership fellow posts were created at NHS Agenda for Change band 8a. Where relevant, fellows’ current terms and conditions were matched and substantive posts protected thus ensuring return to these following the fellowship.
The ADAHP identified a project shortlist linked to current strategic priorities which could be reasonably delivered in a 6-month timeframe. The ADAHP retained budget and operational management responsibility.
The AHP leadership fellow posts were open to all nine professions in the WLT AHP workforce (occupational therapists, physiotherapists, speech and language therapists, dietitians, paramedics, podiatrists, art, drama and music therapists). Recruitment was via expression of interest and interview. There were seven expressions of interest from four of the nine professions in the trust’s AHP workforce. Four AHP leadership fellows were appointed following interview.
The first cohort was UK trained in either occupational therapy or speech and language therapy. At the time of the project, occupational therapists were the largest AHP group forming 60% of the WLT AHP workforce. Speech and language therapists were about 2% of the WLT AHP workforce. For one, allied health was a second career having previously trained and worked as a nurse. All were female with between 9 and 22 years post-qualifying experience. All had undertaken some leadership development; as a minimum, internal trust leadership development and for two fellows, level 7 (masters) programmes or modules. The cohort was ethnically diverse with representation from three different ethnic groups. At least one fellow had significant additional caring responsibilities.
Negotiation with successful candidates ensured assignment of projects which provided an opportunity to build on individual professional and clinical foundations.
The ADAHP met fellows regularly. The cohort formed a peer support group. There was access to the trust’s coaching and mentoring scheme and to more structured leadership training resources via the trust’s subscription to NHS Elect.11
Value for aspiring AHP leaders
Opportunities and experiences regarded as valuable for the AHP leadership fellows as agreed at the Outcomes Workshop are summarised in table 1 and mapped to key aspects of NHS AHP mid-career leadership development (p8)3:
Widening perspectives and boundary testing.
Leaps of faith.
Building a track record.
AHP leadership fellow: valued mid-career leadership opportunities
Participants described practical skills development in project planning and delivery, negotiation, presenting, stakeholder engagement and information technology.
Mentoring and peer support were valuable in navigating and learning from aspects of the projects which felt unfamiliar and/or unsettling:
Applying professional and clinical learning beyond the clinical setting.
Applying clinical leadership behaviours in more strategic contexts.
Mapping experiences to theoretical insights from previous formal learning.
Exploring leadership career possibilities.
Organisational value
At the Outcomes Workshop it was agreed that the fellowship delivered organisational value through:
Delivery of priority projects which in turn demonstrated AHP leadership impact.
Extending the reach of AHP leadership voice across the organisation and wider health system.
Signalling that AHPs are valued by the trust.
Providing visible AHP leadership role models in the workforce.
Retaining, if only in the short term, aspiring AHP leaders who would otherwise have moved on.
Facilitating the ADAHP’s own leadership development opportunity.
Learning for future leadership fellowships
Participants were overwhelmingly positive but also identified ways to strengthen future AHP leadership fellowships:
Linking project and individual objectives to a personal leadership learning plan while encouraging fellows in their chosen approaches to project design and delivery.
Guiding which learning opportunities will be most beneficial, for example, project management, coaching.
Considering access to a third-party coach or mentor, to address sustainability and resource implications with increasing numbers of fellows.
Planning support for frustrations which may arise for fellows returning to substantive roles.
Reviewing all current commitments in and outside of work, to ensure realistic planning for the duration of the secondment.
Discussion
The AHP leadership fellow initiative provided experiential leadership development through opportunities to apply clinical and professional knowledge and skills in new ways to support project design and implementation.
The ethnic diversity and social responsibilities of the first cohort suggest that this approach to AHP leadership development is accessible and inclusive. The evaluation did not explore factors influencing the professional mix of the first cohort or whether redeployments during the COVID-19 pandemic of 2020 limited expressions of interest from the full range of AHPs in the WLT workforce. Future AHP leadership fellow recruitment can be strengthened by considering what barriers may prevent expressions of interest. This is of importance given documented mid-career barriers for aspiring AHP leaders,4 and under-representation of AHPs in senior leadership positions, particularly from smaller professional groups.5
Mentoring and peer support appear to have enabled fellows to challenge taken for granted assumptions and to deliver transformational changes. The experiential project-based learning provided context for theoretical insights gained through previous formal learning. This approach supports positive spirals of leadership development which help to build leadership self-efficacy.12
Linking professional and clinical foundations with wider AHP strategy provided fellows with insights into strategic AHP roles. The project-based approach to leadership has ensured fellows build a leadership track record and gain leadership experience through meaningful project delivery. Learning prompted by experiences of uncertainty in practice has been described as authentic professional learning.13 The project-based learning reported by fellows suggests the initiative has provided authentic leadership learning.
The leadership fellow approach addresses all dimensions of AHP leadership development proposed by NHS England.3 Matching projects purposively to fellow’s interests provided a robust platform for leadership development which builds on clinical and professional foundations and behaviours and widens the aspiring leader’s perspective. AHP practice is increasingly described in terms of four pillars, with leadership pillar development encouraged alongside pre-registration and early career development in the clinical, education and research pillars.14 The leadership fellow opportunity provided a safe mid-career leadership leap of faith by combining a fixed-term project with mentoring, structured learning and the opportunity to return to an existing substantive role. This ensures leadership can be explored as a possible career path without immediately closing the door on clinical practice which may be especially relevant for AHPs who some perceive as reluctant to step away from clinical roles.2 More research is needed to understand if this is reluctance or whether it reflects documented mid-career AHP leadership barriers.4 The safety net which the AHP leadership fellow development offers can support well-being, reduce the risk of losing valuable practitioners from the workforce should they decide leadership is not the right route and potentially encourage those from less well-represented AHP professions5 to consider leadership as a career path.
In creating and evaluating these roles the ADAHP has demonstrated self-awareness, awareness of and for others, openness to alternatives and a willingness to learn by doing things differently. These are among the behaviours described as being a permeable practitioner.15 The initiative arising from this leadership permeability signals that the trust values the AHP workforce. In turn, this potentially promotes the reputation of the trust among AHPs, with associated impact for AHP recruitment and retention.
Conclusion
This small initiative delivered a positive and innovative experiential approach to AHP leadership development. It has demonstrated AHP leadership impact through tangible project delivery which has been influential with senior strategic leaders in the trust and system. Combining with additional structure and learning opportunities could further augment the leadership development value. This approach could be established more widely, ensuring reach across all AHPs, to deliver authentic leadership learning and enhanced leadership self-efficacy. As one participant said:
At a certain point in your career, what you don’t need is to be sent on training courses. What you do need is exposure and opportunity to grow your leadership skills and that’s exactly what these jobs have done and that’s exactly what these people have got out of it.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by St George’s University of London (REC service Evaluation Ref: SE0075) and registered with West London NHS Audit Committee and Research and Development Department. Participants gave informed consent to participate in the study before taking part.
Footnotes
Contributors DH: lead researcher, lead author and guarantor. DH drafted the initial manuscript for review by coauthors, coordinated the response to reviewer comments and revised the manuscript. HL: service lead evaluation participant and contributed to project design, data collection, analysis and interpretation, and manuscript review. LA, TA, VM: evaluation participants contributing to data collection, analysis and interpretation, and manuscript review.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The views expressed in the submitted article are those of the authors and not an official position of employers, institutions or funders.
Competing interests Since September 2021 DH additionally holds the post of Subject Matter Expert in the Centre for Advancing Practice, NHS England. This project was conducting in the course of her academic role at St George’s University of London. St George’s merged with City University to form City St George’s, University of London on 1 August 2024. Evaluation participant and contributor VM, West London NHS Trust at the time of the evaluation reported here and now Hampshire Hospitals NHS Foundation Trust.
Provenance and peer review Not commissioned; externally peer reviewed.