Evidence in practice

The evidence for leadership and leadership development in healthcare is clear.^{Reference West, Armit, Loewenthal, Eckert, West and Lee9} An engaged medical workforce with capable, high-quality leaders has consistently been demonstrated to be integral to driving improvements and supporting high-quality care.^10,11

Complementary to this, there is a growing call at a national level for services funded by the National Health Service (NHS) to strengthen their approach to leadership development and talent management,¹² with future doctors ‘developing an appreciation of leadership at an early stage’.⁶

Leadership development, however, does not suit a ‘one size fits all’ approach. There is little robust evidence for the effectiveness of specific leadership development schemes and difficulty in evaluating their effectiveness.^{Reference West, Armit, Loewenthal, Eckert, West and Lee9} As a result, multiple leadership development programmes have emerged at a national, regional and local level, with various approaches undertaken to meet the diverse needs of doctors, depending on their stage of training, specialty and location.^{Reference Till, Sen and Crimlisk8}

Traditionally, leadership development programmes have focused on so-called ‘horizontal’ leadership development, where individuals attend courses run by external providers which focus at an individual level on ‘what leaders need to know’: developing their knowledge, skills and competencies.^{Reference Petrie13}

Individual interventions alone, however, are insufficient.^{Reference Hewison and Griffith14} Developing leadership crucially depends on context, and leadership development must take place in the context in which an individual works. Within healthcare, this should develop organisational allegiance and engagement in the quality and safety agenda of organisations, maintain a systems focus to meet the challenges of increasingly integrated health and social care services, and develop a strong network between tomorrow's leaders.^{Reference Swanwick and McKimm15} Furthermore, supported by a recent systemic review,^{Reference Lyons, George, Galante, Mafi, Fordwoh and Frich16} mixed external and internal faculty is crucial, with project work and mentoring increasing the likelihood of good organisational outcomes.

The RCPsych Leadership and Management Fellow Scheme draws lessons from this knowledge, other schemes, and the latest educational leadership theory, to combine a national training programme with a local apprenticeship model, so that fellows not only experience ‘horizontal’ leadership development but are also exposed to ‘vertical’ leadership development.^{Reference Petrie13}

‘Vertical’ leadership development focuses on ‘how leaders think’, advancing interdependent styles of more complex, systemic and strategic thought.^{Reference Petrie13} It relies on three primary conditions: ‘heat experiences’, ‘colliding perspectives’ and ‘elevated sense-making’.^{Reference Petrie17} These are described further below, with illustrative quotations reflecting how fellows experienced these ways some of the scheme's fellows have experienced these are reflected in their illustrative quotations below. Fellows consented to anonymised quotes from evaluation data being included in publications.

Heat experiences place fellows in challenging situations where there is a degree of risk. Fellows experience this both in the classroom and through the leadership projects undertaken in their place of work. This is the ‘what’ that disrupts and disorients their traditional thinking to discover new and better ways to make sense of the challenges they face as they assume increasing leadership responsibility:

Colliding perspectives, on the other hand, are the ‘who’. Fellows are exposed to leaders both across the system and within their local organisations, including patient and carer leaders. When combined with the community of learning that they establish with their peers from around the country, fellows are enabled to gather different views and opinions, challenge their existing mental models^{Reference Iles18} and see the world through diverse new perspectives:

Elevated sense-making is the final piece, the ‘how’. In combination with their ‘consulting pairs’, where fellows are partnered to coach each other through the scheme, and senior mentoring locally, fellows are afforded the space to reflect and begin integrating their experiences and new perspectives, to advance their action logics^{Reference Rooke and Torbert19} and leadership effectiveness:

Development

The RCPsych Leadership and Management Fellow Scheme was founded through a joint venture between the College's Psychiatric Trainees Committee, the Leadership and Management Committee and the Specialist Advisor for Workforce. It was first proposed to the Education and Training Committee in February 2017, and although originally modelled on the Royal College of Physicians’ (London) Chief Registrar Scheme, it adopted an alternative model and evolved to embrace a more inclusive approach.

To achieve this, the scheme was modified to be potentially accessible to all higher trainees in psychiatry, including those in less than full time (LTFT) training, without any extension to the duration of their training. It occurred ‘in-programme’, across a 12-month period, averaging 1 day per week, utilising trainees’ protected special interest time. This minimised provider costs, with no requisite for funding fellows' salaries or clinical backfill.

Medical directors from mental health providers across the UK were highly supportive of the scheme, and in the absence of central funding, were prepared to make a financial investment of £2000 per trainee, with full or partial self-funding (including via the trainee's study budget) excluded to maximise equity of access and ensure organisational commitment.

With this early adoption, a competitive tendering process was pursued, with the RCPsych Centre for Advanced Learning and Conferences (CALC) being selected above highly competitive offers from multiple business schools and the Faculty of Medical Leadership and Management (FMLM) to deliver the national leadership development training programme.

Recruitment was delegated to host organisations and supported by training-programme directors, with statements required that fellows had been identified and nominated through an open and competitive process, as determined locally.

We welcomed the first cohort of RCPsych Leadership and Management Fellows in September 2019, with an initial intake of 30 fellows from 19 different service providers; over half were female (57%) and from Black and minority ethnic communities (63%).

Structure

The RCPsych Leadership and Management Fellow Scheme is designed to support the formation of a national network of emerging medical leaders within psychiatry and develop their confidence and ability to operate within and lead across a range of mental health organisations and systems to improve patient care.

It combines a bespoke, high-impact leadership development training programme with a local apprenticeship model, where fellows are mentored by senior medical leaders within their organisations and proactively engage in a variety of leadership projects.

Benefits

Boxes 2 and 3 summarise two fellows' experiences of participating in the scheme, with Box 4 outlining the intended benefits of the RCPsych Leadership and Management Fellow Scheme for individual fellows, the organisations in which they work, and for patient care.

Evolution

The RCPsych Leadership and Management Fellow Scheme is an evolutionary process and key to its future development will be feedback from both fellows and mentors, the needs of our healthcare system and the sociocultural needs of the wider society we lead within.

Although the College has a well-established reputation for delivering leadership and management training, this is the first developmental scheme for trainees. It emerged organically, being co-produced by those for whom it was intended. The scheme will continue to be developed on this basis in order to further adapt and respond to the specific needs of higher trainees in psychiatry, provide value to the sponsoring organisations and achieve FMLM accreditation.

We are proud of our first cohort in 2019–2020, who despite the SARS-CoV-2 pandemic all successfully completed the scheme. We are also pleased to have been able to adapt to an exciting new digitally focused approach for 2020–2021, allowing for more regular contact that will be supported by a new online platform to promote networking, shared learning and reflection.

We acknowledge the challenges that the loss of face-to-face learning involves, particularly regarding the development of close and trusting relationships, but believe that a digital approach will be critical for the future. It not only ensures that mental health services are capable of weathering the current storm, but also that leadership capabilities within the psychiatric workforce are still developed and able to rise to future challenges as we deal with the mental health implications of the SARS-CoV-2 pandemic alongside the implementation of the NHS Long Term Plan.²⁰

Reassuringly, however, although we and many others look forward to the return of face-to-face learning, research from the Centre for Creative Leadership²¹ has highlighted similar levels of results for online leadership training, while providing the additional benefits of increased convenience and accessibility.

Combined with increasing confidence and familiarity with digital engagement, we will therefore integrate these opportunities as face-to-face learning returns and embrace a more blended approach. We hope that this increased flexibility will widen access to the scheme for Category 1 less than full time (LTFT) trainees (i.e. those with health reasons or caring responsibilities) and for those living at a greater geographical distance from the College, by reducing face-to-face learning.

Providing additional value, current alumni have been invited to facilitate action learning sets, and to join the programme faculty for future cohorts. They have also established an RCPsych Leadership and Management Fellow Scheme Alumni Network. This will be integrated with the RCPsych Leadership and Management Committee and future cohorts of the RCPsych Leadership and Management Fellow Scheme. It aims to maintain links between fellows as they become future leaders within mental healthcare across the UK, nurture the next generation through near-peer mentoring, promote collaboration across the system, develop shared learning and good practice, and strengthen the connection between mental health services and the College.

The success of this scheme highlights the appetite for strong medical leadership among progressive healthcare organisations throughout the UK, who recognise the importance of advanced leadership development schemes for aspiring organisational and system leaders.

The scheme has also unearthed a wider unmet need for leadership development among specialty doctors, new consultants and other groups; they of course have their own unique challenges that deserve appropriate recognition. Appreciating this, the scheme is diversifying and strengthening its leadership faculty in order to improve its offer, strengthen its resilience and develop greater resources from which to further develop the leadership and management skills of the wider membership.