Professor Kamaldeep Bhui explains why collaborative leadership is one of the two main pillars of Synergi’s work. At its heart, it holds a respect for difference, dissent, disagreement and disruption to create conditions for change. The piece examines why it offers a means to promote the importance of understanding and eradicating ethnic inequalities in severe mental illness, and a theory of change.

Synergi Collaborative Centre Stroke

Developing a model of collaborative leadership

The Synergi Collaborative Centre is focused on ethnic inequalities in severe mental illness. Not only is it exploring how multiple disadvantages generate and sustain such inequalities, it also plans to investigate how to reduce, remedy or eradicate them.

One of our ambitions is to identify, in collaboration with service users, practitioners, managers, policymakers and commissioners, what the drivers of inequality are and how they prioritise the need to address these issues. Leadership is essential for this to materialise.

We aim to co-create and co-produce evidence narratives, drawing on high quality published research, unpublished reports and documents, as well as knowledge in practice. We propose to use these shared evidence narratives to inspire change in health systems to enable the most marginalised voices to be heard, be visible and not continue to be overlooked within the system of health and social care.

Synergi is testing new models of health systems work to establish networks, and consortia of influential and critical stakeholders, who will work together to propose reforms and implement them, in practice. We are mapping good practice, and we will design, organise and motivate effective actions.

There are multiple, often contrasting and ideologically powerful stories of cause and cure around ethnic inequalities in severe mental illness. These stories are formed, moderated and constantly evolving within relational networks in specific places and social contexts. They involve service user groups and practitioners, along with managers, commissioners and policymakers. To some extent they are all connected, but there are also organisational and cultural boundaries to consider.

The social distance between these spheres of influence appear to hinder effective commitment and movement towards any shared objectives. In part, each group speaks to a different set of performance indicators, raw materials and resources, and trade-offs between priorities, which then fail to attract consensus across local organisations, regions, nationally, or across power structures within any one organisation or system.

Also, some organisations and interest groups feel disempowered, isolated and marginalised, especially if they don’t represent popular and more prevalent voices. Somebody is always left out, feels misrepresented, their voices not heard or respected, leading to protest, opposition or disengagement.

Some service users don’t belong to any service user group, but rely on other social support networks, related to a religious, national or cultural identity. Professionals concerned about equity may be associated with professional bodies rather than service user groups. Alternatively, they may see the very specialist, culturally specific or single narrative groups as irrelevant, or having an undesirable attack or impact on future careers.

Professionals can be swayed by painful and distressing experiences of speaking out against inequalities, discrimination or injustice. But advocating for the dismantling of inequalities could put them under fire from those who fear such actions would reinforce difference, cultural isolation and segregation.

These debates are not easy to overcome. It’s a challenge when various parties, who seemingly want the same outcomes, including better mental health and care experiences for all, are unable to agree on a shared set of actions, agendas or an understanding of the contexts and how best to traction change.

There are also opportunities for more connections to be made through digital links, though this has to be balanced with the healthy and effective use of a new form of virtual relationship. One where there can be an intimacy and distance, and where liminal spaces allow for creativity yet are also transient. This is because in digital spaces, disagreement is often never moderated or negotiated. Each party is sufficiently remote to take up a firm inflexible position, can self select agreeable content and positions, and negate, attack or overlook personally disagreeable perspectives.

Listening and learning across ideological divides takes courage and time and may be perceived as a distraction from business efficiency. This is why new approaches to health systems delivery require sufficient time, space and an appreciation of the need to build connections across diverse constituencies and spheres of influence. This is why collaborative leadership is critical.

 

What is collaborative leadership?

Leadership, in this context, needs to represent an ability to apprehend and hold these apparently irreconcilable positions. It has to sustain, rather than disengage, from people, networks and organisations. It also has to keep opening up emotional, motivational and relational spaces where power transactions, fears and sentiments about what is at stake can be expressed and shared and heard.

This sort of leadership is not about the heroic marshalling of resources or instructions. Well-defined and inflexible action plans which only engage those at the beginning, and neglect anyone who doesn’t sign up to the mission or vision of the change programme, aren’t an option.

We are talking about leadership that cuts across interfaces of organisations and networks, and positions of power and vested interests. It requires the tolerance of uncertainty and the courage to sustain action-focused networks. It looks to maintain influence and optimism, while reducing any perceived threats and fears of failure, or intolerance.

Some of these qualities of leadership are captured in recent trends in NHS service reform. Others are unique to the territory of working with disadvantage, troubled and traumatised populations facing multiple adversities, and when identity and heritage and race and ethnicity related injustices are central.

Societal responses to these groups are not always kind or compassionate. These areas of work provoke some to walk away, others to deprioritise, while some find the necessary conversations troublesome and disquieting. All need leadership that recognises that the power relationship and process affects and move towards collective epistemic trust, confidence and successes.

In short, this is our model of collaborative leadership. This kind of leadership which has, at its heart, a respect for difference, dissent, disagreement and disruption, without which we wouldn’t discover better solutions to longstanding problems.

To Synergi, collaborative leadership involves facilitating the development of organisations by engaging them in critical thinking and discussion. By supporting the acquisition of skills and promoting organisations’ capabilities with local stakeholders, investors, commissioners and influential agencies.

Often, we represent others’ interests above our own, to ensure they are an active, equipped and powerful partner to deliver change. We broker the commissioning of services for other organisations and have been sharing knowledge about evaluation methods with commissioners to ensure they are assessing performance in a fair and transparent way.

Most importantly, we see collaborative leadership as compassionate, caring, emotionally intelligent, relationship-based, adaptive, responsive as well as reflexive, and learning-centred. It requires an awareness of how survival-threats, related to identity, are easily triggered and can provoke aversive reactions leading to disengagement or rivalism.

We want to create the conditions in which change is possible and then foster stakeholders to have the courage to overcome perceived differences of mission or agenda and interests, and to transact across levels of power.

Collaborative leadership, alongside embedded place-based health systems actions, are the two pillars of our burgeoning work. We want to create the conditions for change. We want to promote the importance of understanding and eradicating ethnic inequalities in severe mental illness. And we want to convey the role of multiple disadvantage by bringing alive our theory of change.

 

Useful Resources

NHS Leadership Academy: Healthcare Leadership Model

The Revolution will be Improvised: stories and insights about transforming systems

The Practice of Systems Leadership: Being Confortable with Chaos

Fit for 2020 Report from the NHS Digital Capability Review July 2017

Guidance for NHS commissioners on Equality and Health Inequalities legal duties:

Commissioning for effective service transformation: what have we learnt

PHE : Reducing health inequalities: system, scale and sustainability

Best et al.(2012), Large‐System Transformation in Health Care: A Realist Review. The Milbank Quarterly, 90: 421-456. DOI:

Duffy, S (2013) Imagining the future: Citizenship

Somsak Chunharas & Dame Sally C. Davies (2016) Leadership in Health Systems: A New Agenda for Interactive Leadership, Health Systems & Reform, 2:3, 176-178, DOI: