Bringing Value..what public health specialists bring to local government, and what’s already there

A few weeks ago I started some work with local government and NHS colleagues on the different models which people operate around public health, and what each different field has to offer, and bring to the table. As part of some research, I have been run a few joint NHS-Local Government focus groups on this issue.

This is building on the “find strengths not deficits” approach I have blogged about earlier.

I’m working this up for publication, but here are the immediate things which have come out of it, in the form of some simple propositions:

Public health in local government is alive and well in different forms than in the NHS. It takes a variety of forms from very recognisable (environmental health roles) to the less recognisable (seasonal deaths work) but can always be fitted into the “three domains of public health” model

  • Health Improvement – examples – healthy schools, planning strategies,
  • Health Protection – examples – food hygiene, public protection, trading standards,
  • Service Quality – examples – integrated care pathways in social care, models of service quality, reviewing services against evidence

The opportunity for us is about taking NHS public health strengths to these local government strengths, adding those NHS strengths to what is there already, and from this to create a model of public health which works in local government.  That means we need to recognise both the local government public health family and the NHS public health family have things to bring to the table, and things they need.  I’m not going to talk about the things they need for now, that can be done later. I am going to focus  on what we can both bring to the table.

NHS trained public health specialists do have a formidable range of skills. That’s no insult or poor reflection on local government, it’s just recognising that these folks have a range of domains of competence they can bring to the table. And they can be applied outside public health across the whole authority. I have deliberately not put these solely in the realms of public health (e.g. immunisation uptake or other functions which might transfer) I have tried to put them in the sense of how they can impact positively on the business of the whole council. So what are the skill domains? Well, they are the following:

  1. Understanding the key drivers of health and wellbeing, and the interventions to improve population health
  2. Understanding the principles of how to target programmes, interventions and policies
  3. Understanding and managing the conflicts between population and individual concerns (equity)
  4. Finding, assessing and applying evidence
  5. Understanding and applying structured ways of doing needs analysis
  6. Applying decision analysis and helping with decision and economic analyses of policy
  7. Supporting effective commissioning using 1 – 6 above
  8. Identifying likely prospective policy impact when the evidence is silent
  9. Understanding research and evaluation and applying this to council business
  10. Supporting the evaluation of commissioning
  11. Supporting the understanding of complex variables (e.g. different influences on childhood mental ill health) and their interaction in policy and decision making

These sets of competencies could have a wide and strong application across the NHS and also across local government. Leaving aside the debates about salaries, terms and conditions and risk, those authorities who are having this discussion seem to be developing an ever stronger desire to incorporate public health.

And here is an acid test of them: Take one of your council’s thorniest issues and work out what the public health competencies above could add to help.  Then tell me public health consultants do not have riches to bring to local government.

People already in local government have a range of domains of competence they can bring to the table, and public health specialists who learn these skills to add their portfolio, or combine their skill sets with these, could be really powerfully placed to have a major impact in local government:

  1. Working in political systems
  2. Understanding the complex stakeholders engaged in the policy process
  3. Multiple stakeholder relationship building (good for working with GPs)
  4. Working with multiple policy frameworks from different government and other influencers and stakeholders who feed into local government (much more than the NHS often does)
  5. Policy skills (there is usually a policy unit in local authorities)
  6. Pragmatic research skills (there is usually a research team)
  7. Programme management
  8. Large scale service and intervention delivery
  9. A strong sense of place and its impact on interventions

Interestingly, much of the work on Intervention Mapping as a set of techniques in delivering public health programmes (see Bartholomew et al, Kok et al) and an increasing amount of the research points to the salience of these local government skills in determining whether public health programmes are as effective as they could be.

In social care, for example, there is a significant range of opportunity to benefit from the kind of approach public health has taken with NHS commissioning, using the domains of skills above.

While both of these lists are shorthand,you can see that there are significant opportunities for skills to be used across systems and we should avoid a situation where we might be minimising the skills of someone without close enough consideration of what they can bring to the table.

I’ll share more of this work as I write it up.

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What public health can bring to local government…getting acquainted

Getting to know each other

A few weeks ago I started some work with local government and NHS colleagues on the different models which people operate around public health, and what each different field has to offer, and bring to the table. As part of some research, I have been run a few joint NHS-Local Government focus groups on this issue.

I firmly believe that the opportunities for public health specialists in local government are significant, exciting and worthwhile.  While some folk might be apprehensive (and fair enough, if you’ve been in the NHS for 5, 10 or 15 years, suddenly to be told you’re moving can be quite daunting), I think there are some real opportunities here. As someone who made the jump into local government, it’s a fantastic place to do public health.

Government’s recognition of the need to continue public health input to NHS commissioning in its response to the Futures Forum actually improves the opportunities within public health to focus not just on the important aspects of ensuring NHS commissioning is supported effectively by public health, but gives us tremendous opportunities to work on integrating health and local government services.

So, what have I heard?

1. It’s about mutual skills, not defecits

This is building on the “find strengths not defecits” approach I have blogged about earlier. The idea is that each side has a range of strengths they bring to the table, and a focus which looks to them initially will get further than one which assumes one side has all the strengths, whereas the other has the defecits in skills/knowledge or expertise.

I’m working this up for publication, but there are some immediate things which have come out of this work, and I’d like to share this in the form of some simple propositions:

2. Pubic Health takes a diversity of forms in the NHS, Local Government and elsewhere

We’re used to this concept when we look at community advocacy for health, so it really shouldn’t be difficult for us to accept that public health in local government is alive and well, albeit in some very different forms than in the NHS. Within local government it takes a variety of forms from very recognisable, regulated and accredited (e.g. chartered and legal regulated environmental health roles) to the less formally regulated but still important (seasonal deaths work, seasonal flu vaccine uptake in social care.)

In 1974 the public health family went in a variety of directions,some of it went into the NHS, but not just into the NHS. It’s almost like a series of branches evolved within the NHS and outwith the NHS, with different concerns and issues. And if we can join up the best of each, we could have a fantastic approach to public health.

3. Recognising different branches of public health focus as they evolved after 1974

You can either say that the public health world actually shows distributed leadership (I believe Paul Corrigan hypothesises most on this in his health policy blog) across systems – NHS public health has led on a number of areas with bits of local government focused public health leading on others. If we take a taxonomy approach, we can and should always be able to fit public health work in local government (and in the NHS)  into the “three domains of public health” model we are very used to within the NHS.

Health Improvement.  The key features here are that the work is seeking to improve health of a specific population which experiences worse health outcomes or worse inequalities than the general population. There may also be some general population work (e.g. school meals must meet Government standards) because of the legislative and policy context of local government. We need to understand that universal services in local government can and need to be done in a health improving way, just as we would understand that this is the case in the NHS

Health Protection. The key features here are a regulatory or statutory or policy approach to minimising threats to the health of the population. Food hygiene inspections, trading standards work, animal health are all examples of this in local government. (And let’s not forget that Consultants in Communicable Disease Control derive their legal powers as Proper Officers of the Local Authority.)

Service Quality. Key features here are an attempt to use evidence and tools such as decision analysis and prioritisation to improve services and the outcomes of services. So integrated care pathways are an example of this.

Ok, local government could be a bit more rigorous about using this approach, but if we try this taxonomy out, we might find surprising synergies between and across organisational and cultural boundaries.

4. What each brings to the table
The opportunity for us is about taking NHS public health strengths to local government, add these to what is already there, and create a model of public health which works in local government. It’s not that dissimilar to bringing public health into working more closely with GP Consortia. Those of us who worked with Practice Based Commissioning groups will remember the learning process we all went through then.

So, we need to recognise both the local government public health family and the NHS public health family have things to bring to the table, and things they need. I’m not going to talk about the things they need for now, that can be done later. I am going to focus on what we can both bring to the table.

NHS trained public health specialists have a range of domains of competence they can bring to the table. I have deliberately not put these solely in the realms of public health (e.g. immunisation uptake or other functions which might transfer.) I have tried to put them in the sense of how they can impact positively on the business of the whole council, because I think public health skills could impact on the whole work of the local authority. Indeed, the assumption of the Marmot Review (www.marmotreiew.org)  is that they need to impact on the totality of local government and public sector to achieve the outcomes Marmot set.

So here is an early take on what public health specialists have to offer local government:

  • Understanding key drivers of health and wellbeing, and interventions to improve population health
  • Structured ways of doing needs analysis
  • Decision analysis and helping with economic analyses of policy to help setting outcomes
  • Supporting the understanding of complex variables and their interaction in policy and decision making
  • Resource allocation for policy and interventions
  • Understanding targeting action and interventions to bring most benefit
  • Understanding and manage the conflicts between population and individual concerns (equity)
  • Finding, assessing and applying evidence
  • Supporting effective commissioning using 1,2 and 3 above
  • Evaluation of commissioning against desired outcomes

Public health specialists, especially those who are registered, should recognise this skill set.  These sets of competencies have a wide and strong application across the NHS and they equally can have a wide and strong impact across local government.

Leaving aside the debates about salaries, terms and conditions and risk, those authorities who are having this discussion seem to be developing an ever stronger desire to incorporate public health.

Now , to turn to what local government brings to the table, people already in local government have a range of domains of competence they can bring to the table:

  • Working in political systems
  • Multiple stakeholder relationship building (good for working with GPs)
  • Working with multiple policy frameworks from different government and other influencers and stakeholders who feed into local government (much more than the NHS often does)
  • Policy skills (there is usually a policy unit)
  • Pragmatic research skills (there is usually a research team)
  • Programme management
  • Large scale service and intervention delivery
  • A strong sense of place and its impact on interventions

5. Look for mutual benefit from each side to the other

Interestingly, much of the work on Intervention Mapping as a set of techniques in delivering public health programmes (see Bartholomew et al, Kok et al) and an increasing amount of the research points to the salience of these local government skills in whether public health programmes are as effective as they could be. So public health could benefit strongly from some of these skills and competencies.

While this list is shorthand,you can see that there are significant opportunities for skills to be used across systems.

In social care, for example, there is a significant range of opportunity to benefit from the kind of approach public health has taken with NHS commissioning, using the domains of skills above.

So, to those of my public health colleagues who might be feeling a little concerned about what skills they bring, and what exists, my message is simply take heart. Up and down the country there are processes of learning going on.  Local government doesn’t just want you, it needs you. And that is a potentially very good place to be, without minimising in any way the good of what being in the NHS has brought.

I’ll share more of this work as I write it up.

After the listening exercise…the opportunity

As I get ready to speak to a Local Government Association Session on Public Health at their upcoming conference, I find myself trying to distill my thoughts, and looking back on what I learned from the last session I gave at a conference.

I got asked recently by some Public health colleagues and NHS Non Executive Directors (NEDs), somewhere in England, at a conference session I had been asked to lead whether Public Health was safe in Local Government. “How safe do you feel it has been in the NHS?” I asked. Nods.  This wasn’t a hostile exchange, nor an implication that public health is unsafe in the NHS, nor that it will be less safe in local government or public health England. It was trying to identify what our tasks for public health are now. There was some concern among the NEDs partly because they were very committed to public health, and partly because they were wondering what their leadership role was now.  A conversation ensued over coffee among a small group of us. We missed the next session but over the course of the next hour or so we mapped out together some issues, with a small mix of us, NEDs, PCT staff, a journalist, a civil servant or two and a couple of local authority people all sitting round in a group.

The detail of what happens where and with what resources will be worked out in due course (and we should seek to support and influence that so that forms and structures deliver what will benefit our citizens best)  and discussions will be had, but there is a leadership task – I prefer to call it a leadership opportunity –  for all of us who want public health to be core to our future, and deliver its best.

You may think on reading what I am about to say that I am foolishly optimistic, or too hopeful, or haven’t seen the enormous challenges we have to achieve what Government has set out. Fine. I disagree.  Why? Because it is possible to lead public health into a future where the best of what has been and is NHS public health  thrives along with the best of what it has been, is and can be in local government. And no, I’m not going to share what organisational forms I think that could take. Well, not in this bit anyway. I want to talk about our Leadership Opportunity first.

The leadership opportunity

If you take leadership at its very simplest, it is a set of influencing tools and processes, used by people in a position to use them, to get to a desired state. Public Policy increasingly tells us that such a desired state should be shaped by a range of stakeholders: Commissioners, Clinicians, Elected Members, Non-Execs, Citizens (including those who use what we produce),  other agencies such as community groups, think tanks, research experts and so on. One of the things about Public Health is that at its best we have been good at managing and building such relationships and that skill and tool should serve us well now.

But there are three key things we need to do in working our what our respective leadership opportunities are; i) to work out who we need to influence,  ii) what sets of tools and processes to use, and iii) what our desired state is.  And my own listening and learning tells me that these three things need to be different when we look at short, medium and desired future terms.

I know some public health colleagues tell me I am far more optimistic (I prefer to call it hopeful) about the future than they feel. But it seems to me we have a hugely important set of tasks to achieve, and looking around the public sector, private sector and third sector there are a lot of resources we can use to get there. 

 Trying to lead in situations like this is about making sense of the environment,a process of  trying to identify how best to respond to that environment, and from that to decide ideally what environment we need and how to create it for the future.   Yes, it’s much easier said that done. And yes, I am probably sounding  like one of those inferior “how I led Shmoogley Bumpkins Co from one cheese scone bakery in one city to three”  books you find in airport bookshops. (Don’t tell me you haven’t looked!)  But I really believe this.  And when we examine the value base we share in public health (we do, don’t we?) isn’t that what we get out of bed for in the morning? 

Three leadership oportunities for public health then, and I believe there are quite a lot of people who will appreciate us doing it, from Commissioning colleagues to GPs through to those who will be our next generation of public health specialists.  I can name at least fifteen people who inspired me to come into public health even though it was going through massive change. Who will say that of you or me in the future? That’s really up to us.

Yes, it’s a big job, but if you look at the changes wrought to a number of areas of public service and private enterprise over the last ten years, two points emerge. Firstly, this is a massive opportunity for public health. Secondly, other have done things similar and greater, and have gotten there or are well along the road.  It’s no different for us.  It could be a test of our mettle.

Conceptualising and operationalising the leadership opportunity

I once led a workshop on that title to a bunch of leaders in religious organisations who were trying to come to terms with the cultural challenge of responding to child abuse in their midst. Looking back some years later, those participants I’m still in touch with felt this focus was right. I think personally that I can learn from that experience in the situation I am in now. So, here goes:

The  task, I think, breaks down differently for NEDs, elected members and for us in the core of  public health.

Tasks for Core Public Health – cultural agility and customer focus

  • Short term –  ensuring that we understand what we can offer now and for the short term to a range of stakeholders, and that we do this clearly and that we are seen to add value. Who are our top customers, for what, what products are we offering, with what outcomes? Who owns it, and how can we own the short term tasks together?
  • Medium term –  Keeping an eye on the day job and delivering that while building the future, preparing people for it and working through this complexity.
  • Longer term – Engaging stakeholders in building a vision of what public health could be. How do we work with environmental health? How do we work with GPs?  Culture and relationships will be crucial here

Tasks for Elected Members and Local Government Officers

  • Respect the Cluster and its priorities. Respect consortia and their priorities. And dialogue with them
  • Work with your counterpart NEDs to create and lead some cultural agility from the top – try to interpret the ways of local government to the NHS, and vice versa. Local government is complex, and seems very different indeed from the NHS, to many (not all.)
  • Champion the importance of public health in creating a healthier county, city, borough. See the opportunity and work with NHS and local government colleagues to start on it.
  • Be honest that is is not a matter of public health “leaving” the NHS and “coming back” to local government. Public health is a series of systems, or at the very least a complex web of responsibilities. Some bit of public health have never left local government. Some bits of public health (the GP role in health improvement) will never leave the NHS.  That’s fine. The important thing is how we build the coherent systems in a way that they work together.

Tasks for Non Executive Directors

  • Understand, and promote within your agencies understanding of, the complex cultural and priority issues facing local authorities.
  • Work with your counterpart elected members to ensure together you create an understanding of the challenges the public health family in your area (NHS public health, environmental health, regulatory services, health protection agency and so on) have been facing and the opportunities they have
  • Champion the enduring NHS need for public health contributions to health improvement, service commissioning and quality and health protection
  • Interpret and champion to NHS colleagues the important local government contribution
  • Help public health colleagues build the cultural agility needed for the world of local government

Cultural agility

I’m not in any way denying there is a huge amount of transactional stuff in all this – HR structures, pay scales,asset tracking, and all that important stuff. But if we focus too much on this, and don’t turn the leadership opportunity into concrete things to achieve, we might just find we miss that opportunity.

And I think in trying to turn that leadership opportunity into concrete things, there is something we have left out. That’s what I call cultural agility (I’ll track down the source of that term if you want me to.) What do I mean? Well simply this, the ability to work across different cultures, to understand common aims and ends among them, to understand differences and what they mean, to find and respect in those cultures assets for us to work with, and then to work with them to create something. When you look across an average public health function you see people doing this all the time. Working with communities, applying their diversity skills. The reorganisations proposed, on one level, pose the same challenge of us; and ask us to use the same tool chest.

Making cultural agility live is the same task when we come to Local Government, GP Consortia, Clinicians of myriad hue and Citizens, isn’t it? We need to overcome our fears of the “other” (and let’s be honest, there’s a lot of talking about Local Government as the “other” among some public health colleagues currently whish is unhelpful. Yes, there has also been some unhelpful stuff from some local government people but folks, we really need to change the debate.)

When you look at public health, it becomes very clear that it is a series of systems and functions spread out over a range of institutional hosts. Health Protection Agency, NHS, Local Government, and so on. What makes them work is not beautiful system design, it’s cultural agility and goodwill.

We need to think how we build cultural agility together, across the various bits of the system. Public Health should be good at doing this. I’ll write about cultural agility next time, including some tips on acquiring it, from someone who is by no means an expert.

Meantime, some practical tips on cultural agility:

  1. Do some shared problem solving around a public health issue like Obesity and model solutions now, in 18 months time and in 3 years time
  2. Engage in some function design – take the lead in proposing workable solutions which engage everyone following on from the problem solving,

The role of NEDs and Elected Members, and Cluster Directors and Local Authority Directors could coalesce easily around shared problem solving.

 A Guide to Local Government

As an aid to the issue of cultural agility, I have finished the drafting of  an e-book and a learning presentation on understanding and working with local government with some colleagues. We are currently testing this. We hope to post it online shortly.

Public Health in two-tier local government areas: some tips from experience

One of the issues causing concern among Directors of Public Health in England is how, when and if Public Health transfers to Local Government, you configure public health to work in two-tier areas. By that I mean areas where you have both County Councils and District Councils. (All major Councils in Wales and Scotland are unitary, though both Wales and Scotland have a layer of Community Councils underneath the major Councils. So what I say here applies only to England -including Cornwall  and the Isles of Scilly.)

The model of Public Health in Local Government has been written for unitary or all-purpose authorites, and there have been a number of constitutional fudges over the last ten years or so which have put “top-tier” authorities (unitaries or Counties) in charge of some things. The phrase “top-tier” can sometimes feel patronising to District Authorities. But there are ways of making Public Health in two-tier Local Government areas work.

This blog is written from the perspective of someone who has worked in Public Health in the NHS, and has had a range of public health and Public Health roles in and around Local Government. I love Local Government and am passionate about its role, history, potential and significance.

I have worked in a number of two-tier areas, either as an employee or a Consultant, and the key is to understand the respective powers, duties, issues and concerns of each Council, the politics between them and how you can play them in to achieve your objectives. Ok, much more simple than it is, but in eleven years working across multi-tier areas in one capacity or another it has never failed me.

So, here are the things which have worked for me:

Firstly, understand that Local Authorities essentially fall into three Categories 

  •  Principal Councils are those which undertake major functions like Housing or Social Care. In London and many places these are all-purpose unitary councils. But England has a long tradition of two-tier local govermThese are Counties and Districts in County areas. The phrase “two-tier” essentially means you have two types of Authority. Counties cover a whole County such as Warwickshire or Dorset. Districts or Boroughs within the County cover a part of the County, such as Dorchester.
  • Local councils are parish or town councils which are very local. More about these later. In some ways calling an area two-tier is a misnomer when there are Parish councils around. Parish Councils can be significant for public health.
  • Specific purpose authorities are those like the North York Moors National Park Authority, and in some places specific Joint Fire Authorities, which usually exist in places where the Fire Service covers a number of local authorities, such as Tyne and Wear.

Secondly, understand what powers you might want to work with. Principal Authorities in two-tier areas have the following division of functions:

County Councils

  • Social Care for Adults
  • Childrens Care
  • Schools
  • Adult and Child Safeguarding
  • Health and Wellbeing Partnerships (proposed)
  • Category 1 Responder for Civil Contingencies Act
  • Waste disposal
  • Crime and Disorder Reduction Partnerships
  • Consumer Protection and Trading Standards
  • Strategic Planning
  • Libraries
  • Transport
  • Animal Licensing

District Councils (may also be called Borough Councils) 

  • Planning Control and local planning
  • Housing
  • Environmental Health
  • Waste collection
  • Building Regulation
  • Appointment of Proper Officers for Public Health Act purposes
  • Appointment of Proper Officers for Section 47 National Assistance Act
  • Disease Notification
  • Category 1 Responder for Civil Contingencies Act

All councils have different powers on similar issues

  • Leisure services and Culture have duties and powers across Districts, Counties and even Parishes
  • Roads and highways (Counties, Districts and Parishes all have different functions)

Parish Councils (sometimes called Town Councils)

Parish Councils vary enormously in size and functions. We might be tempted to think of the Vicar of Dibley when we look at Parish Councils but some of these very local bodies do struggle while others have functions and budgets not far off several million, often undertaking functions on behalf of their District and County sisters. You can find a really useful guide to the surprising powers of Parish Councils here http://www.townforum.org.uk/servicesstructure/parishcouncilguide2007.pdf. You can also find two very useful quick reads, The Role of Parish Councils http://www.camlink.org.uk/wiki/The_role_of_the_Parish_Council and the National Association of Local Councils, which is the Parish and Town Council answer to the Local Government Association http://www.nalc.gov.uk/Default.aspx

There are a whole host of things which Parish Councils can do you might not know about:

  • The provision of community facilities ranging from allotments to bars, laundrettes and even mortuaries, cycle parks, swimming pools and green spaces.
  • Undertaking functions on behalf of other councils
  • The right to raise a local precept for their parish through council tax collection

But equally importantly, they can help you engage local communities with policy changes, the Joint Strategic Needs Assessment, etc.

What’s in a name?

You  will find some councils in Counties may be called Districts or Boroughs. There is little difference, really just ceremonial and historical. Boroughs are districts which have been granted the title of Borough and can have a Mayor. Technically their councillors can be addressed as Burgesses not Councillors. Districts have a Chairman, not a Mayor.

Parish Councils and Town Councils essentially have the same functions they just exist in a rural or less rural area, or around a market town or historic town respectively.

Some Top Tips for Public Health to Understand

Thirdly, think through these top tips to develop a strategy for influencing and working across:

  1. Bear with me here, I’m going to give you the essence of what Psychology has to say on expert-novice differences and tell you why it’s important to you. The key difference between an expert and a novice in a field, according to psychological research, is that experts not only know the subject (i.e. have domain-specific knowledge of issues like environmental health and housing) but they can relate that knowledge to other areas of knowledge (i.e. how housing and social care interact) and can create mental maps and landscapes of how to work within and across those. What that means for you is get to know the Councils, understand how you can knit things together to create an integrated approach to public health, and understand who can help you.  A friendly local government lawyer is usually a help; while having both a County and a District member as a mentor can help too, especially if the two get on well and will agree to mentor you in joint sessions.
  2. The Elected Member theme here is crucial.  County Members and District Members have both different portfolios (housing, social care) and common concerns (their local area and electorate.) Personally I think elected members are crucial to making public health work and building an effective relationship with them is key. They have a difficult, not very well remunerated and often thankless task which they have to fight to be able to discharge. But they are a rich resource of learning and collaboration. The top tips are to remember – they are elected, you are not; you need to understand with both Chief Officers and Members when to relate to whom; treating them with respect and keeping some clear boundaries between their role and yours and finally staying politically impartial are all important. This comes with practice, hence finding a mentor.
  3. Remember always that Local Government in England has been around for centuries, so historical anomalies are important and you should accept these. The fact that the Common Council of the City of London and the Common Council of the Isles of Scilly have some unique functions is just one of these anomalies, and the fact that the Common Sergeant of the Inner Temple is actually a Local Authority (is He the only Local Authority who goes to bed at night?) is another.  Localism has been around for centuries, and the quirks and quaintnesses of local authorities up and down the land is just one manifestation of this rich heritage.
  4. Even if the public health transition intended in the White Paper is ultimately significantly downplayed or changed, Local Government remains crucial to the achievement of better health for our population. Counties and Districts, and Parish Councils can all have roles and they all have powers and duties you will probably want to tap into.
  5. While you will want to work in a two-tier area with both Districts and Counties (e.g. work with environmental health on food hygiene and education on school health) you need to understand that minimising the role of Parishes could be counter-productive. Make sure you think about Parishes, they can often be very helpful.
  6. Think about options for working together before or even without whatever comes out of the NHS listening exercise. Understand that there are models around for collaboration in two-tier areas already. Despite the political differences and challenges, Councils in two-tier areas often have a history of working together. They may have joint boards constituted between them (e.g. Joint Drainage Boards) which can give you governance models. There is probably a countywide Community Safety Network whose models you can learn from.
  7. Professional bodies often work well across counties. Trading Standards (County) and Environmental Health (District) often come together in networks for regulatory affairs. How can you use these to help? Similarly the lawyers might meet. The Chief Execs almost certainly do and there may be a members’ liaison forum.
  8. Professional groups are important sources of good practice in Local Government. Think about this. Can you work with the local Chartered Institute of Housing branch to help include housing people? Equally, the Chartered Institute of Environmental Health is a crucial body. It has now opened its doors to people from all public health backgrounds, and a good vote of confidence if you really want to be embedded in local government might be to join, and gain value and possibly some respect from your local government peers. I have decided to do this and am putting together my application and portfolio. Let’s hope I make the grade!
  9. Understand that local government thinks it never lost some aspects of public health. The Local Better Regulation Board with the Chartered Institute of Public Health and the LACoRs [Local Authority Co-ordinators of Regulatory Services] put together an excellent paper on the contribution by these bodies to public health. Get and read a copy! http://www.lbro.org.uk/
  10.  Think about whether, in the transition, you might want to set up a Joint Public Health Board, through agreement between the Authorities. Members and Officers can be given appropriate delegated powers within schemes of delegation.  The Council’s Lawyers (sometimes in Counties called The County Secretary) should be someone you want to speak to.  You might even want to consider the use of Agency Powers under the Local Government Act 1972, where one Council can arrange for another to carry out some of its functions as an “agent” on the commissioning Council’s behalf.
  11. Most Counties have shared County Level strategies and will have learning from this experience you can tap into.
  12. Counties and Districts have their own networks within the Local Government Association. These can be rich sources of learning. There is a County or District somewhere that has grappled with the constitutional, administrative or configuration challenge you are facing, so network!
  13. Make sure you are a regular visitor to the Local Government Association Website www.lga.gov.uk and if your Council is a member of the Local Government Information Unit , a Local Government Think Tank, you could benefit from making sure you see their publications. www.lgiu.org.uk

I hope this helps. Working in single tier areas brings is own challenges, but working effectively in two-tier areas can really bring its own rewards.

Further Reading

You can get some basic readings on two-tier local government here

http://www.idea.gov.uk/idk/core/page.do?pageId=1121355

http://www.direct.gov.uk/en/Governmentcitizensandrights/UKgovernment/Localgovernment/DG_073310

Jim McManus (2011) Understanding Local Government – a guide for public health professionals. E Book. Forthcoming

Sir Alfred Hill, Birmingham’s Public Health Pioneer

Sir Alfred Hill

Birmingham’s first Medical Officer of Health 1866-1903

You can read about other Medical Officers of Health here

http://en.wikipedia.org/wiki/Medical_Officer_for_Health#cite_note-hardy03-1

Until he retired in 1903,he threw his energies into improving the health of the City. By dint of will and effort,working with Chamberlain and as President of the Society of Public Analysts he wrought changes to sanitation,housing,food purity and living conditions which we still enjoy the legacy of today. He was obsessed with improving housing, food quality, sewage and the quality of health and life of the poorest in Biringham. He became President of the Society of Public Analysts and Society of Medical Officers of Health. He was a major pioneer in the destruction of tens of thousands of slum dwellings in Birmingham and their rebuilding. An unsung figure without whose work and dedication Birmingham would not be Birmingham.

 Hill surveyed the health of the City every year,and set about addressing what he saw as key problems. If he returned today,I think there are a number of things he would want to tell us. Several of them might well begin with “why on earth did you…?” But he would give us insights that would be important to the health of our City. Hill knew that living conditions were key to health,and in his own language expressed that being able to have good quality of life,education,housing and purpose were all important to good health. His arguments about public parks and housing are still revelant today.

2011 is the 14th anniversary of his appointment.  We intend to hold some events to help us look at priorities. 2016 is his 150th anniversary. We hope we can celebrate it with you.

More reading to understand what public health is all about

Continuing the series on what to read to understand public health, there are two excellent books which I think will suit two different, but overlapping, readerships.

Now, none of these books are a laugh a minute, but then they weren’t intended to be and neither is this blog.  Each of these books helped me, and each of these books approached in a structured way will help you.

Ross C Brownson et al, Evidence Based Public Health. Second Edition

 Oxford University Press (USA). 2010. Hardback. ISBN 978-0195397895

 Yes, one person on Amazon has described this book as “unreadably boring”. I think that assessment is simply rubbish.  This book twinned with Donaldson and Donaldson Essential Public Health is a good pairing.  Brownson gives you a structured set of tools and approaches, Donaldson gives you a good grounding in key policy and approaches from a British context.

Read this book if:

  1. You are new to public health or someone from another field wanting to be in the know about some things these odd public health people do all day, and understand whether there might be something in it that helps you achieve your aims for better public services
  2. You want to understand the cycle of what public health practice is and are prepared to follow a reasonably structured approach
  3. You are concerned about making a difference to what you do using evidence
  4. You want to understand how evaluation can help you
  5. You are a bit of a “newbie” to searching and using evidence
  6. You are a trained and experienced public health professional and have had the role of training people in any of 1-6 given to you.

I’ve used this book with planners, housing professionals, social care commissioners, childrens’ commissioners, policy staff and environmental health officers.

Some of the chapters in this book can be used on their own. For example, I used Chapter 8 – “Developing and Prioritizing Intervention Options” on its own as the basis of a working group with some voluntary sector professionals wanting to do work on health improvement.  I’ve also used Chapter 7, “Searching the Scientific Literature and Organizing Information” with trainees, and Chapter 2 on “Assessing Evidence” makes a really good first read for people wanting to be evidence-informed in their practice.

If you work in the third sector, local government or NHS in the UK, you should be able quite easily to recognise where the US context of this book and the UK policy context differs. The fact that this book is written from a US context does not, in my view, detract from its value.

Use this book to dip into and out of, but if you are reading a chapter you need to read the whole Chapter to get the best out of it.

The book has a lot of helpful diagrams, and links to further reading and websites. I think this is a good book for preparing people to be public health minded and use public health in their work. Brownson has a high web presence to boot, with many articles, tools and presentations across the web which people can learn from.

Muir Gray, Evidence-Based  Healthcare And Public Health – How to make decisions about Health Services and Public Health. Third Edition

Churchill Livingstone. 2009. Paperback. ISBN 978-0-443-10123-6

 There are times I feel that I should mention Muir Gray’s hallowed name with some kind of honorific or a slight bow of reverence. Knight of the Realm, CBE, sometime director of the National Knowledge Service for the NHS ; NHS Chief Knowledge Officer; Professor of Knowledge Management in the Nuffield Department of Surgery at the University of Oxford; and Director of Better Value Healthcare Ltd, UK . You get the picture.

Sir Muir is a man who shares his knowledge and insight and leaves his mark on you. Love him or dislike him, this man will leave a welcome and helpful mark upon your practice and methods if you are amenable. If you don’t believe me just google him. An oft-used quote which sums him up is:

 ‘In the 21st century, knowledge is the key element to improving health. In the same way that people need clean, clear water, they have a right to clean, clear knowledge’

 This book is fantastic. Ok, I’m biased, but rarely a month goes by when I don’t consult my tatty copy of this book to help me understand and check that I am getting the best from the evidence and information I am using to advise people.

 Read this book if:

  1. You are  i) someone such as an Environmental Health Officer or Graduate in another field,  ii) you are working in public service including third sector, iii) you have a grasp of public health principles and iv)  you want to hone your skills in evidence-based public health practice
  2. You want more on managerial decision making in the use of evidence for prioritizing than perhaps
  3. You are employed in public health or are a GP or commissioner and want to make sure you are improving the public’s health through your work
  4. You are a Director or Consultant in Public Health and sometimes feel you have developed major short term memory problems
  5. You want to put a periodic check in that you are practising effectively in evidence-based work
  6. You’ve read Brownson and are looking for the next stage

 Muir Gray writes well and shares significant experience.

These books are good and valuable reads. Brownson is almost a mini course in public health methodology. Muir Gray is a toure de force in evidence-based practice. Both should help you.

Teresa of Avila and the psychology of prayer

Formidable woman

One of the great joys of Carmelite Sprituality is the works of the great 15th Century Spanish mystic, Teresa of Jesus, or Teresa of Avila.  She , her works and her reform of the Carmelite Order marked both a continuity and a major development from its origin in the Latin Hermits on Mount Carmel in the Holy Land. And today, tens of thousands of people find her insights, and those of the many Carmelite writers she attracted and shaped,  salient, valid and real.

Teresa was a formidable woman. Rowan Williams’ study of her is an incredible read. I’ve now read it so many times the binding and pages have fallen apart.

Teresa was a woman of Jewish descent in a Spain obsessed by limpieza de sangre, purity of blood from Islamic and Jewish origin.  She was a religious who dared to write on prayer and mysticism during the height of the Inquisition, when not only mystical prayer was frowned upon, but at a time when the validity of women as people of theological and spiritual wisdom and insight was itself a thing of suspicion by the inquisition, if not near derision.  She and some of her work was denounced to the Inquisition.

And in spite of this, she delivered a reform of the Carmelite Order which saw her travel the width and breadth of Spain in the most hostile geographic, political and theological climate; and is one of the 33 Doctors of the Church.

A visit to Avila, her home City, is both inspiring and humorous. One thing about Teresa, and her ally in the Carmelite reform, St John of the Cross, is that there is some seriously mediocre art about them. This is, though, in many ways quite fitting. I have a love-hate relationship with Bernini’s statue of St Teresa in Ecstacy in Rome. He captures in some ways the encounter with the divine, but in other ways I can’t help chuckle because I think Teresa would have hated it. The mediocre, rough, worn and frankly wonky array of second rate portraiture of Teresa in the museum of the Saint in Avila capture far better the  drive, determination and sheer fire of this women than Bernini’s – admittedly profound – capture of Teresa’s moment of being utterly caught up in ecstacy.

Those of us in the Carmelite family (Friars, Sisters and us Secular/lay Carmelites), even us baby neophytes, are preparing for the fifth centenary of her birth in 2015.  As part of this we are reading once again through her works and listening to her.

The website here  http://www.iwasbornforyou.com/ is a major guide to this process. And you can read about the Carmelite Secular Order here http://en.wikipedia.org/wiki/Secular_Order_of_Discalced_Carmelites

There are so many books on Teresa that I have added links below, rather than suggest one single book. Or you can register with www.cibi.ie for the Carmelite Institute’s excellent distance learning courses on her.

But to get to the point, I think we need to fundamentally re-examine our approach to using different schools of Psychology to understand and dialogue with Teresa, and as we prepare for her 2015 I think it’s about time we started with listening to her, really listening to what she has to say, as a starting point.

Her works on prayer

The teachings on prayer are those I keep coming back to, being challenged and inspired by.

Teresa gives us a great discourse on prayer in Chapters 11 – 22 of  her book The Life, with Chapter 8 being almost a prelude to this.  The restatement of this in another of her works The Interior Castle is essentially meant for the more advanced. Teresa is writing from her own experience.  The discourses on prayer in The Way of Perfection are equally challenging.

Prayer and the four ways of watering a garden

She talks about the ascent of the Soul in prayer as being like four ways of watering a Garden. The stages progress by the Soul feeling it does most of the work at the beginning to God doing the work and the Soul enjoying the presence and gift of God rather than having to work laboriously at it. (Though Teresa says in The Life that prayer is a gift and when we look back we see God doing and giving, not us just working.)

The first method draws water from a well to water the garden by buckets. It is laborious. This is vocal prayer as well as the discursive prayer of meditating on something. It is difficult to focus attention on God, and easy to be distracted.

The second type is less work for the person, but still needs more effort. It is a waterwheel with hoppers/dippers. The wheel turns by human work, water flows into a conduit which takes it to the garden. St Teresa says this stage means “the soul begins to recollect itself, borders on the supernatural. . . . This state is a recollecting of the faculties within the soul, so that its enjoyment of that contentment may provide greater delight” (The Life, chap. 13). It is less difficult to focus on God than in the well.

The third and fourth types require decreasing human effort and no human effort respectively, unlike the first two. But there is a continuum between two and three.
The third type is a running stream irrigating the garden through an aqueduct. This stage says Jordan Aumann OP, is mystical; that is, all the faculties are centered on God” and Teresa says it’s a “union of the soul” with God. She describes this kind of prayer as a “sleep of the faculties” because God completely enthrals them. This kind of prayer makes it difficult to not focus on God, rather than be distracted.

The fourth type is irrigation by rain. The soul simply enjoys the rain, produced by God and delivered by God. Aumann says “This stage of prayer is totally mystical, meaning that it is infused by God and is not attained by human effort. It is called the prayer of union, and it admits of varying degrees. “

A friend of mine once introduced me to the plays of Lorca, where water is used as an erotic metaphor, and also a spiritual metaphor. And I find the use of water as a metaphor for prayer instinctively connects with me. It raises the memory of prayer at its best and the desire for relationship with God , as a thirst which only God can quench. So I find I drink up what Teresa says here, and keep returning to it to try and understand it.

I find this first stage immensely reassuring because Teresa says this type of prayer is something we never abandon. And my experience is that prayer is sometimes very hard, thirsty work. And that reassures me when I find prayer hard work and feel I’m not getting where I want to be in relationship with God.

Further, the notions of embracing the cross, living as God wants us to, preparing for conversation and trying to build a relationship, along with the practical tips on staying with it are immensely helpful. And Teresa here sometimes makes us laugh at ourselves.

It also reassures me that I am not wrong to desire for better prayer and better relationship, but keep my feet on the ground with this type of prayer, and the hoping has to come from love of God, not being in love with prayer. Finally, feeling one is going backwards is not always a bad thing.

The psychology of prayer and Teresa

Over the years I have often been asked to talk, lead workshops and lecture on the relationship between Psychology and Theology.  I’m no expert on psychology and theology, so don’t assume I am an infallible guide. 

Equally I am no expert on Teresa. The best guide to Teresa I have met remains a 70+ year old Secular Carmelite who taught me more about Lectio Divina in four sentences over a coffee than I learned from several years of exhausting, frustrating and sometimes duff attempts. 

I just happen to be someone trying to dialogue psychology with theology and in the process seem to have amassed a library.

And naturally, the psychological dialogue with Teresa has captured my interest along the way.  I have seen, and read, piles of the work on various schools of psychology and Teresa: depth psychology, Jungian psychology, Freudian psychology and several other psychology schools which seem to be oft used by people studying spirituality. An awful lot of it seems to come from that 1970s over-emphasis on counselling and psychotherapy that after Vatican II sent some clergy and members of religious orders into counselling ministries as if it were sometimes seen to be the primary expression of pastoral theology.

Now don’t get me wrong. Counselling and therapeutic ministry is hugely important. I wouldn’t have spent over twenty years volunteering in the fields of bereavement, human health and lately working with the church on responding to sexual abuse by clergy if I didn’t. And one time in my life when I went off the rails big time, well I benefited from wise listening by a religious sister.  So I am not rubbishing this whole set of schools.

What I am saying is that if we are honest – and when it comes to pet insights on psychology we rarely are – one single Western twentieth century set of schools focused on therapy do not begin to encompass adequately the antropological insight of Christianity. It’s not a case of supplanting psychological insights from the Christian and pre-Christian centuries with  the ever-changing fads of that odd collection of methods, disciplines and schools we inadequately try to encapsulate with the term “psychology.”  It is a case of dialoguing and retaining the valid from our tradition.  Drink from the well of secular wisdom by all means, but don’t let’s forget the riches we have.  And if you read some of the recent works on psychology and Catholicism, any historical perspective realises that purely approaching someone like Teresa from a purely psychodynamic or depth psychology perspective is a narrowing of the relationship between Catholicism and Psychology, not a flourishing.

 I often seem to find people studying the Church and its mystics from the light of one or other early to mid twentieth century intrapersonal psychology schools. Their choice of psychology schools seems  sometimes to be limited to the point of cliché, while ignoring the riches of experimental and other areas of psychological science. Thomas Aquinas, for example, still has much to teach us in that amazingly complex area between psychology and philosophy we call either the psychology of consciousness or the philosophy of mind. And for that matter, Teresa has too.

And we should always bear in mind that just because one person  feels Freudian and Jungian psychology are salient areas for study of Christian spirituality, there are still those who would dialogue with or dispute  the insights of those schools of psychology, and wish to widen the debate. 

And this leads me to venture that the Catholic Church ought recover a relationship with psychology which is a little more discerning, a little less uncritical, and a bit more aware of its own riches.

This overdependence on forms of psychology akin to counselling and therapy, and especially the psychodynamic, I think puts too many limits on our ability to receive Teresa’s writing on spiritual life and the psychology of spiritual life and religion without putting on filters which sooner or later can become unhelpful. The point is seeing Teresa, not Jung or Adler or Rogers through Teresa.

It’s entirely understandable we might want to dialogue psychology and Teresa, but the psychology and theology debate is far wider than schools of psychology which are essentially aligned to Jung, Rogers, Klein, Freud or others of what one could call a broad existential/symbolic/theory driven stream of psychology. Indeed there are some psychologists who would claim that Freud and Jung simply cannot be classified within the group of disciplines which make up psychology, claiming they are more akin to esoteric philosophy. So those of us dialoguing Teresa with psychology have a duty not to make truth claims or superiority claims about one bit of psychology in this debate. Because it’s usually the bit of psychology we like. And this narrowness is in danger of doing those who want to read Teresa a disservice.

And I’m not making a case here for empirically driven experimental insights as supreme, before someone jumps to that hoary old chestnut. I’m talking about being open to a wider world of psychological insight than that offered by one particular set of schools. 

Sources of dissatisfaction

I have found that so far many of the attempts from this school to dialogue with Teresa sooner or later become problematic, for several reasons.

Firstly, most of these schools (especially Jung and Freud) part from a Christian anthropology at some point or another. That is not Teresa, even someone of my limited understanding of her can see that. There comes a point where you have to concede, in my view, that the anthropologies of Freud and Jung – however valuable some of their insights for therapy – simply cannot be reconciled with a Christian view of what it means to be human, and in particular the doctrine of grace and the significance of Christ without watering down the latter and heading for some rather dated faddish Semi-Pelagian or Gnostic nonsense.

Secondly, Teresa’s psychology  strikes me the more I read and reflect as being actually stunningly profound. So in a dialogue with Freud or Jung or Rogers or Adler, the latter can become pretty limited dialogue partners, or even redundant. Do we need Jung to understand what Teresa has to teach us about the human condition? Teresa remains clearly and sometimes painfully relevant and insightful.  Sometimes the obsession with the modern method of dialoguing too strongly contemporary insights with the teachers from another era can actually dilute the strength and salience of what the previous era has to offer. Nowhere is that more strongly present for me than in the four waters of prayer, and the first water particularly. A cognitive psychologist, a psychologist of memory and a neuropsychologist could all bring insights to this debate which can shape and help our understanding.

Thirdly, some of Teresa’s discourse on memory and intellect and imagination is about as spot on as you would get in a current cognitive psychology text. Teresa was no fool, and it strikes me that in listening to her we should bear this in mind before we start ransacking through any other discipline.

Teresa has much to be said in her own right as a psychologist of religious experience. Teresa is, in being a doctor of prayer, a profound psychologist of discipleship, and nowhere is this more apparent than in the four waters.

Widening the debate between Psychology and Carmel

So, if a lot of the psychology talked about Carmel has some value but  can be problematic and needs to be widened, how do we do that?

Well, in preparing for the fifth centenary, I’d like to suggest a very first start at some principles:

  1. Take Teresa as the starting point – after all, for Carmelites that should be the point. And there is nothing methodologically, scientifically or psychologically wrong in that. In fact, you find a lot more empirical evidence in bits of Teresa than you will in Freud – at least she tested her experience and theory with her community and her spiritual directors, which is more than Freud always did.
  2. Listen to her first before we dive headlong into other disciplines.
  3. Understand the breadth of what Psychology can bring to dialogue, not just one school. So don’t pretend or purport that one school of psychology is supreme in this project.
  4. Let’s not take ourselves too seriously – after all, she didn’t.
  5. Teresa is always in and for the Church. You can’t divorce a reading of Teresa from the context of living relationship within the Church, within community and with God. Hyper-individualism is not Teresian. Teresa’s anthropology is a relational one.
  6. Gift not guilt. Teresa makes much of our limits and propensity to go awry. But at the end of the day, the point is grace not guilt. Some schools of psychology are not methodologically or conceptually equipped to deal with a Christian understanding of forgiveness.
  7. If we can’t reconcile our reading of Teresa through psychology with principles like Humility, Detachment and Love of God and Neighbour, how can we claim it to be an authentic reading of her?
  8. If we can’t reconcile our reading of Teresa through psychology with the wisdom of the Church through the ages, how can we claim it to be authentic?
  9. Teresa’s Psychology makes no sense without a firm doctrine of the Grace of God and a God who wants relationship. That is not a perspective shared by all of the psychologies often used to try to read her. But more importantly, this starting point creates a whole context for a Christian psychology dialoguing from Teresa.
  10. Recognise that Teresa’s fundamental starting point is that to be fully human means to be fully open to God. In that sense, Teresa is probably one of the most authentic guides to Catholic understanding of the human we can have.
  11. Recognise that for us, psychology is one part of the knowledge that makes up a Christian understanding of what it means to be human, and what it means to relate. This is often called theological anthropology. our reading of psychology needs to be in harmony with our understanding of the human person.

Time permitting, I’d like to develop these thoughts and principles. But so far her they are, and let’s see how far we get with them.

Some Readings and Links

C.Kevin Gillespie, Psychology and American Catholicism. Crossroad,2001.

Robert Kugelman, Psychology and Catholicism:Contested Boundaries. Oxford University Press, 2011

The best editions of Teresa’s works can be found at the Institute of Carmelite Studies Website, and the best bookshop on all things Carmelite is the Carmelite Book Service http://www.carmelite.org.uk/acatalog/index.html

 ICS publications has Amazon Kindle editions of some of Teresa’s works and other Carmelite works. http://www.icspublications.org/

Discalced Carmelites www.carmelite.org.uk