Introduction

We are two health visitors who independently undertook higher degrees to understand and respond to changing expectations informing new public health activity, family visiting and children’s health in communities and came together to share experiences. Our individual journeys of discovery involved researching and learning while practising as we each endeavoured to improve what we were doing to influence the health of our communities. Ruth, in a large rural village and Robyn, in an inner city practice, independently reached similar conclusions about ‘ways of being’ with people that promote the wellbeing of those with greatest health need. We will describe our separate learning experiences to show how we arrived at our current understanding of leadership in working with individual families, community groups, colleagues and other agencies. Although our experiences are drawn from health visiting, leadership in public health practice is not discipline specific. Our learning is influenced by a range of professional and academic disciplines in the field. For this reason we believe the key messages are transferable.

Our intention is not to produce a model of good leadership practice for others to follow, but to share our experiences in the hope it is valuable to you in your reflections. We chose a first person narrative (Connelly & Clandinin 1990) to show the developmental personal nature of our learning and to bear you, the reader, in mind as we write. Leadership qualities appear indistinguishable from effective health visiting relationships and each of us felt clear before we began that leadership is not about being first, best or most powerful. Our enquiring process clarified relationship qualities and skills we now find effective and leadership involves using professional power by acting in ways that influence change towards agreed aims. Sharing power to support change may be the most important feature of the public health practice we find effective. We utilise knowledge available to us from a range of sources, including our own beliefs and values, as we share with you our search for improved understanding in a process we now call practice-as-enquiry. Our leadership styles are guided by personally held interpretations of professional values that we independently developed through practical experience. The similarity of our explanations is of interest to us because we both intend promoting collaborative thinking and action planning with clients, communities and colleagues for improving how we all work together. This chapter explains how and why we arrived at our leadership styles and improved our effectiveness. We will tell our stories separately before integrating themes. Box 12.1 introduces the values and skills that we now recognise are individually constructed in our alongside leadership styles.

Ruth’s story: practice development

My interest in community development in a large rural village emerged from an MSc in Health Studies (Grant 2001). I used interviews, a focus group and questionnaires to understand lay perspectives of health and for identifying service requirements for those in greatest need. Here, I explain my learning through reflection on community development activity following the MSc. I now call it ‘micro’ public health. I will show how my understanding of leadership for promoting social inclusion developed.

Although the reflective journey is mine, I would like to acknowledge my colleague Annie Saberwal, who was a source of excellence and unselfish inspiration to me. The journey began when health visiting was required to change from universal child- and family-focused public health work to targeting those with greatest health needs (Department of Health (DH) 1998a). Health visitors were encouraged to adopt population-based public health roles in order to address the needs of their communities. At the time there was little information on methods for working effectively with populations (Parston & Timmins 1998). Statistical data I had gathered for an area health profile gave little insight into the needs of the population. I was aware I had not worked effectively with families who were poorest, socially excluded and suffered the worst health. Although, like all clients, they were offered a universal service, this group did not call on my support as often as more articulate, affluent members of the community. I believed this indicated they did not feel comfortable with me, although research shows this was the group most likely to suffer ill health in my case load (DH 1998b). For this reason I decided to find a more effective method of improving health in this population. At the same time, the government encouraged practition-ers to work towards a range of interventions to improve the nation’s health and set primary care trusts (PCTs) a number of targeted objectives (DH 1999, 2000). Until I had a clear picture of the health needs of my local population, I did not know how to begin.

Discoveries

In research for an MSc in Health Studies (Grant 2001), I discovered some of the health needs of the large rural village (5700 population) in which I work. The aim of the study was to determine the unexpressed health need of the population in order to maximise health gains and target health inequalities. Community participatory appraisal (CPA) is frequently used by the World Health Organization to gather information on health needs of a population where little is known (Ong & Humphris 1994). CPA research has shown that professionals are often unaware of community benefits that may be obtained from relatively simple solutions (Sewell & Wade 2000). Obstacles to change are sometimes revealed by the process and communities empowered to act. Furthermore, communities hold knowledge that can influence the development of polices and service provision that are more likely to be effective (Johnston & Mayoux 1998). I undertook a needs analysis to determine lay perspectives of health using CPA methodology (Grant 2005). Semi-structured face-to-face interviews with 11 adults were analysed followed by a focus group with seven adults. A questionnaire was developed based on data generated from interviews, the WHO Quality of Life study (WHO 1998) and Orientation to Life questionnaires (Antonovsky 1993). The amalgamated questionnaire was posted to 350 adults randomly selected from the general med-ical practice list. I elicited a good response (40%). The predominant feature of the interviews and focus group was that the divided nature of the village impinged on social cohesion and health of the population. Questionnaire respondents suggested a link road to the village, a supermarket, banking facilities, evening doctors’ surgeries, a State-run nursery, wrap-around child care and leisure activities. An important finding was the level of psychological distress amongst males, particularly in the 18–25 age group. To the Quality of Life question about anxiety and despair, 12.5% of most male age groups reported feeling severe anxiety and despair ‘frequently’ and ‘always’. This increased to 42% in the 18- to 25-year age group.

Other findings pertinent to the poorest population in the social housing area, was rural isolation (8 miles from the nearest town) and lower educational achievement and life expectancy. This group showed a ‘sense of coherence’ profile similar to more affluent owner occupiers in the new estate, but with more respondents in the highest and lowest scoring categories (Antonovsky 1998). Plotted on a graph, a parabola emerged demonstrating normal distribution of the ‘sense of coherence’ scores across the whole community. My purpose in determining the ‘Orientation to Life’ of the population by using Antonovsky’s ‘Sense of Coherence’ questionnaire was so that I could discover if there was a group of individuals who would have greater health needs in the future. These data revealed that the 45- to 65-year-old age group has the most ‘low’ scorers, who have a poorer sense of coherence and are, therefore, less likely to cope well in adversity as they age. This information, plus my knowledge of families, informed my decision to work at addressing the health needs of the poorest population. Many of the low-income families lived in the same social housing estate, thus they also belonged to a geographical or neighbourhood community. I spent time learning all I could about the local voluntary and statutory service provision.

Beginning to reach the socially excluded – sustainability

It was my plan to start a group and, as community leaders merged, train them to continue the group. I was keen to build in this element of sustainability so that I would then be free to address other ‘communities of need’. In order to start a group I produced an invitation to a meeting that was delivered to 350 residents in the social housing estate. I was encouraged when around 30 men, women and children came. I recognised they were from amongst the poorer, more socially excluded members of our village. Lots of ideas for a group were offered but they also expressed doubts that it could be sustained. They told me about a group started by the local authority that had collapsed acrimoniously. I provided refreshments and listened. I decided to be client led with this group in the same way as I try to be in my family practice and research. Although this sounds like the opposite of leadership, it was a conscious decision as a strategy for empowering this population to take responsibility for their future health, including social and fiscal health. I needed to provide exactly what they wanted so that they would want to make use of the services. I had to recognise that this may not be what I thought was good for them. Even so I still made errors. At about the same time I learned of the opportunity to join a co-enquiry group Robyn was running. As the project unfolded I decided to use an action research process of critical reflection and action in order to learn and develop effective ways to practice, and thereby influence healthy changes.

In the beginning, what they wanted was a meeting place to enjoy company and have fun. They also wanted computer lessons and free computers to take home. Sixty attended computer courses during the following year and received second-hand computers. I wanted to provide parenting classes. I found other parents attended the classes, not those from the group I was most concerned about. Much later, when they trusted me, I was told that parenting and household duties were the areas in which they felt confident. I acknowledged I had been disrespectful by suggesting that parenting classes were necessary. It reinforced my determination to be led by them. I had to learn how best to do that as I went along. I decided to commit to facilitating the group for one morning a week for a year. I remained confident that by the end of the year, community development techniques would have enabled members to take over the group and run it without my help. It was important to me that the group should sustain itself after I had withdrawn as I recognised some health gains would be slow to evolve. I was to learn that it would take longer than a year to support this community in working together. The reason why previous attempts to develop such a group had not succeeded were complex, but one compelling reason was the withdrawal of the previous local authority community development worker.

Containment, reciprocity, reassurance and encouragement

Initially I was exhausted by group members. Some people shouted at me about what they wanted, some expressed doubt about my ability to help them. Others spoke harshly, were rude and lacked confidence that the group would continue. Every week a traumatic event occurred and members moved from one house to another retelling the story. I surmised that a great deal of energy was spent in anxiety and distress. Perhaps this was why many appeared to struggle emotionally and lack emotional literacy, and the energy to develop their lives. One week the crisis was a domestic violence incident in which a man, armed with a knife, chased his screaming wife around the estate. Another week youths poured petrol onto a cat and set fire to it. Yet another week, a 33-year-old woman in the third trimester of pregnancy died of a heart attack. Her baby was delivered by emergency caesarean and died 3 months later. These examples demonstrate the ser-ious nature of the crises people commonly experienced on the estate. Some of the residents act as ‘emotional amplifiers’ spreading news that affects other people. Many residents have poor emotional literacy and problem-solving skills and, thus, share in the trauma these experiences generate. My colleague, Annie, and I interpret this emotional cyclone to be the result of poor physical and emotional health. We concluded that in order to help we needed to buttress their emotional health whilst teaching them new emotional literacy skills.

From the start of the group I became aware of using psychotherapeutic skills, particularly ‘containment’ (Shuttleworth 1999). Containment involves emotionally holding distressed people until they are no longer afraid and can begin to cope. I became conscious of how I Iistened supported and encouraged people. I also used Brazleton’s notion of reciprocity. I realised that by being sensitive and responsive to moods I could enable the members to cope with their problems (Brazelton 1992). Some said they found this helpful. Each meeting a crowd gathered and reported the latest disaster. After Annie and I helped them think it through, they relaxed and started chatting. Some began to think creatively about activities for the group. Gradually, we witnessed people becoming more optimistic. This role became an important part of our work. I now recognise that by using different skills I began to develop a style of leadership useful for this particular depth of need.

Annie and I used our knowledge of local services to arrange exercise classes, yoga, Tai Chi and family fun days. I observed that small children spent most of their time either on their parent’s lap or in their pushchairs. Few parents actively played with their children. Older children played amongst themselves. Recently, a play worker has begun introducing young parents and their children to new ways of playing in the group. She also makes visits to their homes. Funding was provided from government Children’s Centre money following a successful bid. I notice some parents have begun playing with children during group activities. One young mother, whose first child had been compulsorily adopted, continually berated her 2-year-old, ‘Get up, get down, get off’. Lacking language, the child was timid and anxious. By learning to play, he has grown in confidence, increased his use of language and appears a happier little boy. His mother, meantime, has also given up smoking and is considering seeking work. I learned that through our modelling ways of being together, and by teaching parents and children to play, parents now appear to appreciate being with the older children. I recognise that these skills are part of my leadership style. I now know that there may be greater success to be found in working with families to help meet their needs than from pursuing a child protection route.

Slowly, as confidence in Annie and me grew, I found members would run to the surgery and burst in on us when they were worried. I was delighted to realise they had become comfortable with us and sought us out to share their difficulties. It made me aware of the complex, time- and energy-consuming nature of the problems people frequently faced. One day a very fat young man ran sweating into my room to tell me that two men were dealing drugs in a car outside his home. He was angry that they were ‘shooting up’ and throwing discarded syringes in the gutter in front of his children. These men threatened him and he was afraid. Not knowing how to handle the situation he ran to the surgery to be comforted and to seek advice. I realised that sometimes I must be prepared to give advice and accept the lack of knowledge in some areas. I identified advice amongst my leadership styles. Some people expected me to know everything and to be able to sort out all their problems. I felt overwhelmed by the burden, but my growing respect for these families made me realise that if they can learn to carry their awesome burdens, then I have helped them in a small way. I observed that as families learn to put down other people’s problems they become clearer on how to tackle their own. My understanding grew about the impact of living in rural poverty in an estate where families with multiple problems were housed. I worked at attracting services to the area and in time was joined by the Citizens Advice Bureau outreach worker whose knowledge and help about welfare benefits, debt management and many other topics has been invaluable. Annie has ably demonstrated her wonderful art and drama skills by producing an act for the local community play and running a hugely successful ‘POP Idols’ competition, as well as continuing to carry a great deal of the daily practice management.

I was amazed at the resilience of group members and began to understand the ‘Sense of Coherence’ scores from Antonovsky’s Orientation to Life questionnaire I had used. They appeared not to lack self-esteem, but to have heightened sensitivity to problems experienced by their neighbours. On the whole, many appear to feel good about themselves, but to have little resilience to cope with emotional challenges. General practitioners reported reduction in frequency of consultations amongst people who attend the group and began recommending it to other patients who frequently attend the surgery. During the last 2 years, six lifelong smokers have given up, with support from a smoking cessation specialist who comes to the group. Other resources and activities are listed in Box 12.2.

Box 12.2