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Complex public health challenges and
local action: How does local government tackle complexity?
Health Foundation Webinar, 2nd November 2017
Professor Jim McManus
Director of Public Health, Hertfordshire County Council
Health Foundation Generation Q Fellow
@jimmcmanusph
1 sec
www.hertfordshire.gov.uk
Webinar presentation : complex public
health challenges and local action
http://www.health.org.uk/events/webinar-complex-public-health-
challenges-and-local-action-how-does-local-government-tackle
www.hertfordshire.gov.uk
Background to Webinar
This presentation is done for a Health Foundation Webinar on 2nd November 2017 on how local authorities manage complexity in public health. Health Foundation webinars can be viewed here http://www.health.org.uk/collection/webinars
In 2017 local authorities find themselves challenged by a variety of persistent and stubborn public health problems such as obesity, air pollution and alcohol-related harm. All take place within complex systems, with multiple factors operating over many decades in contexts that adapt and change over time.This webinar explores why we need to think about these public health challenges in terms of complex systems and therefore use different evidence and develop new, more effective approaches to tackling them. We will bring together practice and research perspectives to discuss how we use this thinking to design and evaluate population-level interventions differently to improve health.
Speakers
•Professor Harry Rutter, Senior Clinical Research Fellow at London School of Hygiene and Tropical Medicine
•Professor Jim McManus, Director of Public Health, Hertfordshire County Council
•Jane Landon, Strategy Advisor, The Health Foundation.
www.hertfordshire.gov.uk
Aims for this webinar....
• To share practical information with our audiences about the need to develop a new model of evidence to help policy makers and public health practitioners develop and evaluate more effective responses to public health challenges.
• To explore why we need to think about these challenges in terms of complex systems, use different evidence and develop new, more effective approaches. It will bring together practice and research perspectives to discuss how we use this thinking to design and evaluate population-level interventions differently to improve health.
www.hertfordshire.gov.uk
The system I face every day…
• Life is complex, it’s the models that are too simplistic
– Complexity is part and parcel of what local authorities do, we just haven’t always labelled it
– By contrast I think Public Health has not always been so at ease with complexity
• The paradigm of the evidence pyramid can’t handle complexity…
• two examples of complexity coming……
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Key points about local government
• Since at least the mid-2000s, local government has increasingly come to see its role as being an enabler,
– bringing together groups of people, from transport to economic growth, regeneration, troubled families, public health
– becoming ‘place shapers’ than just direct service providers.
– For local govt it’s pointless to use something inaccessible or over-complicated
– Action oriented not triumph of theory over practice
15 secs
www.hertfordshire.gov.uk
My organisation and system• 1.2million residents, 37 major settlements
• Three tiers of local government
• 100+ key partners
• £817 million revenue budget 2017/18
• £223 million capital budget 2017/18
• 8000 staff
• 78 councillors
• 4 main offices, 15 touch downs (soon to be 17) (DOWN from 25)
• 46 libraries
• 29 fire stations
• 537 schools
• 17 household waste recycling centres
• Maintain 3,000 miles of roads and pavements, 100,000 street lights, and 118,000 signs.
2,200+ statutory
responsibilities
www.hertfordshire.gov.uk
Mechanisms and Levers in complex
systems• A variety of different
mechanisms and levers, from political to officer and technical, can be brought to bear by local government on complex issues. We need to think and operate in this space comfortably
• Statutory duties
• Statutory powers
• Discretionary powers
• Influence
• Assets
• partnerships
Key issue is to
be able to use a
range of them
appropriately
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So how do I work with a systems
approach? – a mental frameworkLevel of analysis
(Iterate between these)
Models and tools
Conceptualise the world you’re trying
to influence
Use systems tools here – causal loops,
network diagrams, systems analyses. A
range of tools and techniques
Consider the levels of influence both
biological to environmental and across
the lifecourse
(The Six levels and layers)
Consider the evidence paradigm You don’t need randomized controlled
trials for bridges!
Refine and adapt as you go on to build
your “multi-layered model” of the reality
you are working with
Systems tools and approaches
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Public Mental Health: Complexity is a given for influences. So it should be for policy
Source: Hertfordshire Public Health Strategy 2014-17
© Copyright, Hertfordshire County Council 2014
The range of stressors mean we need to take a systems approach to conceptualise them properly.
Systems approaches can help us conceptualise these, and their inter-relationships, as well as hypothesise about actions
TALK THROUGH THE EXAMPLE TO ILLUSTRATE THE POINT
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LGBTQ Young People
systems analysis identified actions to take
Levels
• Environment/Organisation
• Interpersonal
• Intrapersonal
Example High Level Tasks
• Policy, training, systematic monitoring, access, quality, Building
• social norms
• LGB literate public services, LGB equality in work/education/services
• Resilience, self worth, LGB literate health care
www.hertfordshire.gov.uk
Tobacco
Control and
the six levels
of system
action
Remember this is a model. If
you started somewhere else,
eg modelling influences from
manufacturers, your system
analysis would be different
Source: Hertfordshire Public Health Strategy 2014-17
© Copyright, Hertfordshire County Council 2014
www.hertfordshire.gov.uk
What have I learned after 5 years trying?
• This is a different style of working, influencing and advocating
• Systems thinking becomes a tool for leadership in your portfolio
• It sits alongside other tools and skills
• Agility of thinking and repertoire of tools become watchwords
• How you apply these is as crucial as being able to choose
• As much art as science
www.hertfordshire.gov.uk
Getting to be comfortable with systems
approaches as a leadership task
• Reflection upon the world while engaged in practice in order to change it
www.hertfordshire.gov.uk
Systems leadership as an example:
prevention in an entire population system
What we’re currently trying to do – Hearts, Minds, Action
1. Attempt to do system wide prevention eg
1. Children and young people
2. Adults with disabilities and care needs
3. Contractors
4. Employees
5. Use our own assets to meet our healthy housing ambitions for the population – Herts Living Ltd Property Company
6. Facilitating collaboration across sectors (eg 7 tasks for employers for mentally healthy workplaces)
2. Use systems approaches to understand, prioritise, act and adapt
3. Using the cycle in the previous slide to guide this process
4. Symphonic Thinking
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Symphonic thinking key to leadership in
complex systems
Symphonic thinking is the signature ability of composers and conductors, whose jobs involve corralling a diverse group of notes, instruments, and performers producing a unified and pleasing sound. Entrepreneurs and inventors have long relied on this ability. But today, Symphony is becoming an essential aptitude for a much wider swath of the population.”
Daniel H. Pink (2005)
A Whole New Mind: Moving from the Information Age to the Conceptual Age
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use tools but stay true to reality
“Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only.
It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system.”
Avedis Donabedian
(pioneer of healthcare quality approaches)
www.hertfordshire.gov.uk
Some golden rules
Take the plunge, don’t just talk
• If you’ve never worked in local government:
– don’t take a deficit approach – “the expert”
– spend some time in the system before you pontificate
• If you’re in a local system:
– Use systems in the cycle of reflection and action
– start somewhere,
– get others on board
– Work across the system
– Walk before you can run
