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.

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