Co-producing public health in local government, and top reads for councillors

 

A few days ago I tweeted, asking what folk would have as their top reads for elected councillors.   I did this the same week as we had our first Public Health and Localism Cabinet Panel .

So before I do the list of reads, allow me to digress a little (or indeed a lot) about the learning process both Directors of Public Health (DsPH) and elected members are going through. This is just my very personal take from what I’ve heard and seen from other DsPH and members, and colleagues at LGA and elsewhere.

I have been a local government employee on and off for over nine years, and have spent much of the rest of my career working alongside local authorities from national organizations. Local government is something I am passionate about. I feel privileged to be involved with the work at INLOGOV And I think Local Government is the right place for Public Health to be, for reasons I have enumerated ad nauseam elsewhere.

But I am on a very steep learning curve currently, with new arrangements and systems. And so are many of my colleagues. Our HR Dept and our Learning and Organizational Development function within that is helping us by finding experienced local government mentors for our senior team.

Passionate and strong elected leadership

At the same time as the officers are gearing up for this agenda, so are elected members. What became very apparent very quickly in the first public meeting  of our new Public Health and Localism Cabinet Panel was that not only do we have a very focused and commited Executive Member and Deputy but we also have a group of extremely interested and passionate councillors up for the debate, across County, Districts and Towns/Parishes. In fact our induction session on public health attracted nearly half of all councillors and over-ran into coffee time because of the number of questions.

The questions and contributions alone at the Panel have given us enough strategy and evidence work to keep us busy. My only regret was that it will take us time to do justice to the level of thought and questioning that had been going on before and during the meeting. Just one question on Obesity alone could have kept us going for an afternoon’s focus on what we want to achieve.

So I work in a system where people are up for the work and the challenge. I know it’s not the same for everyone, but this strikes me as a great place to be.

The councillors and evidence debate

During the run up to transition from 2010, I got rather impatient with the number of people who repeated what I felt was a not very well thought through mantra that “councillors are not evidence-based.”  Not only is it not true, it isn’t helpful either.

Councillors have to balance a range of factors in coming to a decision and a view. So do we as officers in coming to formulate our advice and proposals. Understanding and exploring that with each other is a journey I always find helpful. Our job as officers is to advise, guide and support using our expertise. And to be honest, I have never yet had a coffee with a councillor where I haven’t learned something about how to do my job better and serve them better. And I have never met a councillor who didn’t impress me by their work and enthusiasm for their population.  Approaching each other in a spirit of generosity is what I have found to be crucial, because in such an atmosphere, when each side makes mistakes, the other can help.

In the past month I have had some amazing discussions with officers and members, and overheard others, about why Lifecourse and Proportionate Universalism concepts are important to our public health agenda, and about the worrying patterns which emerge when you compare us against ourselves, rather than against England. In fact, all of these concepts have been taken up into our Health and Wellbeing Strategy with enthusiasm. We now have to deliver on them.

Our public health roadshow round elected members at all three tiers of local government always has a slide on the determinants of health. I have yet to have a single meeting on this where members don’t start trying to understand that within their context.  And I can add to that CCG colleagues, HealthWatch, voluntary agencies and a host of others.

Interested members

Here are just some of the questions elected members across all tiers of local government, and not just in our area, have been emailing me in the last month:

  1. What are the best reads for me in my new role?
  2. If I wanted a quick introduction to public health, where would I get it? (I tried to sell Oxford University Press the idea of producing one of their very short introductions, there are any number of people in the public health world who could write that well, to no avail)
  3. What are the best websites and newsletters for me to keep up to date given I am a councillor not an officer, and have limited time?
  4. I’ve found this research paper. Is it any good, does it translate from US/Australia/wherever to UK contexts?
  5. How do you as our DPH stay up to date with all this?
  6. I’ve had an email/letter from (insert national charity of choice) lobbying me on (insert health issue of choice)…can I talk to you?
  7. Can we have a CPD session on evidence in public health?

If that’s a sign of things to come, I think public health will thrive in local government. The key issue for us is to find the right way of working and the right way of supporting, providing the right balance of information, evidence and guidance without doing too much or putting people off with technicalities. That’s going to be a learning curve, but one I welcome.

One thing, however, is clear. our local Policymakers want public health to be right and to deliver.

Finding a way of working: co-producing public health

Dominic Harrison, the DPH for Blackburn with Darwen, recently gave his take on the DPH role in relation to policy.  This is clearly an issue which DsPH and elected members will need to work together on locally and nationally so we have clear lines, clear cultures and strong relationships. It does need some development time, and the nature of local government is that what works in one area may well be different in another. And if we’re honest, the NHS wasn’t necessarily all that different, was it?

I have been on a learning curve about working with users, patients, carers, third sector organisations and clinicians in co-producing health pathways over the past few years. In several roles I have had some fantastic help from an organization called Governance International, which has links with INLOGOV and are about to kick start more work on this locally.  Governance International believes that co-production is a better model for public services and communities  because it “is about professionals and citizens making better use of each other’s assets, resources and contributions to achieve better outcomes or improved efficiency.”

I feel this is a good model for supporting elected members in arriving at their new policy decisions in these confusing and overlapping worlds of Health and Wellbeing, Integration of Health and Social Care and Public Health in an informed way. It strikes me that the job of building robust and effective public health in Local Government needs to be co-produced with elected members deciding policy and also officers and members working productively with a range of stakeholders. And actually, that concept isn’t really new. The context, players and methods might be. But as DsPH we have experience and skills we can bring to this agenda. What we have done before can apply if we reflect through it.

I can think of endless reasons for why we should co-produce public health but let me just pick five:

  1. When we stop and think, we can’t do public health without co-production. And a lot of us have been doing this. We just need to apply our skills to the new world and learn the new context
  2. A little thing called the law and the legal role of elected members in an elected democracy is an added reason. They are there to decide policy and to govern. And in any case they have experience and understanding we as officers don’t. Equally, as officers we have expertise others do not
  3. The determinants of public health need a whole system approach and a variety of different strategies. No single bit of the system has all the pieces of the jigsaw puzzle, and we all need to work together
  4. In my experience, if you can get users, carers, the public, elected members, volunteers and professionals all understanding and agreeing with an agenda, then there is more likelihood that the agenda is the right one and will deliver results.
  5. Accountability to others for how we exercise stewardship of the talent and knowledge in public health is never a bad thing. And we should share our knowledge lightly as service to others.

So, while we are on this journey locally, we will be doing a number of things to try to co-produce public health from the Strategy to the services to the approach to learning and deciding.

Development of Directors of Public Health and their teams

It strikes me that some of the various development opportunities on offer for DsPH haven’t yet got to grips with this agenda. There is an overlap between public health and health and wellbeing Boards, and the Integration agenda,  but there are also very important distinctions and differences which public health needs to work on, which health and wellbeing Boards need to know is happening, but which they won’t get into the detail of.  Health Protection and infection control are just two examples of this.

We need to get the balance right here, and sometimes we do too much detail. Expecting elected health portfolio members to sit through an entire day on the technicalities of screening and immunisation, for example, feels a bit like expecting the Fire Service portfolio holder to sit through a day on the design and implementation of gas masks. We need to be clear what is important for members, what is important for officers, and what isn’t.

We still have a public health system in England which doesn’t yet understand local government as fully as it needs to. I don’t intend this as any criticism, it’s just a statement of how I see the world. Perhaps the best way to improve that is for members and experienced officers to work together with DsPH new to this world through learning sets or mentoring.

And those bits of the system which don’t understand local government or don’t understand public health need to admit this, accept that they have to learn, and learn with the rest of us. Otherwise we won’t move on as quickly as we need to.

There is a strong role for ADPH here, and I was immensely heartened by the discussion at the ADPH policy workshop recently, and by the presentation from Kevin Fenton at Public Health England (PHE).  I think ADPH will become increasingly more important as the voice of and support for DsPH in ways that other bits of the system cannot be. This is not a  criticism, it is just about recognising the complexities of local government are very different from the previous NHS system, and we need ADPH, FPH, PHE, LGA and others to do their roles well and in a way which also co-produces the new public health world.

Back to the reading list

In the meantime, here are those books people tweeted, and a massive thanks to so many of you who tweeted. This felt like the public health world being very supportive. You may agree or disagree or just wonder about these choices. I will think about my own suggestions, and invite you to add more using comments below. I’d also welcome comments on what you think this list is saying more generally about what we think elected members might want to know.

The straight into the detail

Status Syndrome by Michael Marmot

Essential Public Health by Donaldson as a primer

The Marmot Review of Health Inequalities in England

How to Stay Sane by Phillippa Perry

Ecological Public Health by Rayner and Lang

Bowling Alone, by Putnam

Disease Maps by Koch

Spirit Level

Unequal Health

The reads to help understand the strange and wonderful mindset of Public Health:

The Geek Manifesto, a compelling read on the politics of evidence

Ben Goldacre’s Bad Science

The Patient Paradox by Margaret McCartney

The quirky

Women on the edge of time by Margaret Piercey. Kathryn Ingold suggests this could stimulate councillors’ imagination, vision and ideas

The Jungle by Upton Sinclair  – the importance of social models

The Book of Leviticus (because it chronicles some approaches to population health. A modern version was suggested so here is the NRSV, a modern ecumenical translation and the King James for those of you who prefer that.  For a thought provoking translation try the 1930s translation by Msgr Ronald Knox.

The man who planted trees by Jean Giono

The Book of Nehemiah for , the importance of engaging communities in visioning and building. Again modern version (NRSV) and the King James.

And finally:

Paul Ogden at the LGA suggests Marmot or Brave New World, saying a society in thrall to science and regulated by sophisticated methods of social control.  I thought that was ASDA on a Friday.

I’m not quite sure what I could suggest after all that!  Comments welcome.

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What is this personal “resilience” thing and why should we care anyway?

A number of my very patient colleagues have had to endure me banging on about “resilience” recently. Because I hadn’t explained myself brilliantly well, some folk had quite reasonably assumed I was going on about emergency planning or another ‘flu pandemic.

Actually I was talking about resilience as a psychological and behavioural attribute. The things which enable people to appraise and find ways of dealing with things which may cause stress or challenges to their health.

Derek Mowbray, a psychologist working in this field (about whom more later) describes personal resilience as “a process of getting a robust attitude in the face of challenging and threatening events. It’s also about becoming a stronger person as a consequence of facing up to and overcoming challenging experiences.”  He explains in two sentences around 50 years of psychological research.  Those of you with an interest in spirituality will also find strong similarities here in the research which shows spirituality is a strong aid to personal coping, resilience and wellbeing.

But I digress.  The point is, resilience as a psychological construct has evidence around it sufficient to warrant policymakers, practitioners and commissioners taking it seriously as an aid to keeping people as well as possible, and helping them manage their challenges.

Take the field of public mental health, for example. There is growing evidence that neighbourhood stress (poor environment, fear of crime, poor housing etc) adds to the burden on people and becomes a set of vulnerability factors [things which make people more susceptible] to poor mental health. Some recent work on Social Capital in Scotland, for example,http://www.gcph.co.uk/assets/0000/3647/Social_capital_final_2013.pdf reinforces this.

But why should people in health, social care and public health bother?

Well, the research suggests resilience as a construct or attribute can do a number of things for us:

  1. Help people cope with long term conditions and create the behavioural and emotional foundations for good self-care and self-management
  2. Help people cope with life and both prevent some common mental disorders arising and help those living with mental health challenges at low levels to adjust to daily life
  3. Help children and young people grow up well-adjusted and ready for life,
  4. Help people cope with their differences from the rest of society, especially LGBT people finding it difficult to come out
  5. Help carers care for themselves and remain well while caring for others

That sounds like an ambitious agenda, doesn’t it?  But aren’t these outcomes which have been at the core of clinical and public health ambition for ages?

It’s part of my ongoing ambition that behavioural sciences including psychology can help us find models which contribute to achieving these outcomes.

And there is a long research pedigree, which has been around since before the now much vaunted (and valuable) field of positive psychology.

One reading which has had an effect on me is Alex Zautra’s chapter on “Resilience: A new definition of health for people and communities” in pages 3-29 of Reich, et al (2010) Handbook of Adult Resilience http://www.amazon.co.uk/Handbook-Adult-Resilience-John-Reich/dp/146250647X 

They identify that risk factor research (starting with the Framingham Study in 1951 so public health colleagues take note) ” has a long and successful history of identifying biological and psychosocial vulnerabilities to chronic, as well as acute, illness. ”

They ask the question of how people “sustain themselves while ill, and how do so many who are ill recover?” They offer “resilience as an integrative construct that provides an approach to understanding how people and their communities achieve and sustain health and well-being in the face of adversity. Our aim is to define resilience based on current thinking in biopsychosocial disciplines, to outline key research methods employed to study resilience, and to suggest how this approach may further the development of public health and other intervention programs designed to promote health and well-being.”

Since I read this Chapter, I have read probably over 100 other papers which I think underpin the work they do. The challenge for us is operationalize this, to translate this stuff into useable methods and tools which have some evidence behind them, or are promising enough for us to commission and evaluate.

What are the big points in resilience, then?

This field is burgeoning, but here are some key starter points:

  1. Patient, carer and professional need to know that building resilience is a journey. It requires work.
  2. Attitude and outlook on life and your challenges are hugely important, thinking patterns which are not self-limiting, self-destructive or avoidant help you get here
  3. Being able to (i) appraise threats, stressors (potential sources of stress or which test your ability to cope) and daily life, (ii) identify realistically the ability to cope and (iii) identify the strategies you need to deploy to stay well and in control are important
  4. A portfolio of coping skills and techniques (e.g. breathing techniques for people with COPD) for daily challenges is needed, along with the ability to use these to turn daily challenges into routine non-threatening stressors
  5. Non cognitive coping resources (support packages, social support, engagement)
  6. You need some clear steps to take when you’re feeling overwhelmed and steps 3 and 4 aren’t working
  7. You need to know when to ask for help, knowing what help to ask for, and knowing where to go to
  8. You need regular feedback from others (professionals and those in the same situation) on how you’re doing

Now that doesn’t sound too complicated, does it?  There is a good American Psychological Association reading resource and indeed a leaflet on this here http://www.apa.org/helpcenter/road-resilience.aspx

Resilience strategies have been successfully used with people with HIV, people recovering from Stroke and people with drug and alcohol problems for some years. Many of us just probably never called them that and never really used the full range of tools we could to enhance and deliver effectiveness.

And this is just one problem with how we use, misuse, abuse and underuse behavioural sciences in the health and social care system: we don’t really get it right, it’s bitty and incomplete and then we wonder why it isn’t working. We often think we know it and it’s common sense. Behavioural science at its best should be simple, but it’s not always common sense. Behaviour science can be very counter-intuitive. We may, perversely, over-complicate behavioural science, or not pick the right intervention, or get the pathway wrong.

The “what” of what resilience should be in daily life is frequently (unintentionally) sabotaged by how professionals and systems are organized.  But if a public health skill is to identify successful interventions which are evidence-based, and then implement them with fidelity to the evidence, you’d think we should be able to overcome these challenges.

I believe that we often put behavioural science contributions in the too difficult box. If you feel you know it all already then please reconsider, you’re probably missing something.  If you feel it’s too complicated then usually you’ve been reading research that hasn’t translated well out of research into English.

The list of of reasons I’ve just reeled off covers most of the factors where behavioural science approaches haven’t worked well. It’s not the science, it’s how well we use it.

As a way round this, I believe the evidence demonstrates that if we combined behavioural science know-how with practical experience on designing and implementing systems, and getting the right culture to make it work, we could actually make a substantial contribution to the health of people and the workload of our health system. That’s what I want to try to do.

What about resilience for me as a worker/carer/volunteer?

There is an important issue here in what some people call “self-care”. Resilience for those of us working in the challenges posed by our population and our health and social care system is going to become increasingly important if we are to stay the course.

Occupational Psychology has a wealth of learning to offer on how workers who are personally resilient are more effective, efficient, healthier and have better outlooks on life. Having faced some big health challenges recently and taken on a new job, I decided to work my way through Derek Mowbray’s Guide to Personal Resilience. http://www.mas.org.uk/publications/personal-resilience.html 

Ok, Ok, he’s a Chartered Psychologist and you already know I have a bias towards psychology, largely because I am a psychologist by background and because I think there is ample evidence we need to learn more from psychology in health and social policy and the running of public services. But this stuff works.

Mowbray takes you through a questionnaire on your own resilience, and helps you look at things like self-awareness, determination, your vision for what you want to achieve, your organization, relationships, interaction and problem solving and so on. He also gives 18 tips for resilience.

So where next?

I am aiming to get some psychologists and behavioural scientists together with clinicians to look at what we might achieve. If you think you can contribute to this agenda, I’d love to hear from you.

Seeing the wood for the trees: Participatory Planning in Public Health

Sometimes you need a method for trying to make sense of an issue when everybody has a different perspective and you need to deliver some clarity and direction.  And sometimes you need to get people to see beyond the trees of different evidence articles and try to produce a synthesis of what the issues are, informed by evidence.  I don’t know about you but I find this can be extraordinarily difficult.

So I want to share with you two methods which work for me. The first is search conferencing for participatory planning when you are ready to build your strategy and want to work out from a range of stakeholders where you are headed.

The second is what I call the “Principles and Direction Sift” where you’re not sure you’re even ready to get a plan together, or where you might be but everyone seems to be pulling in different directions based on what they’ve read.

The Search Conference

For some time I have been using the Search Conference method for participatory planning. In the US it is widely used for community action.  The problem with this method is it can be a little cumbersome in the planning and running, when you’re not even at that stage yet.  But if you want some of my favourite reading on this try

Emery and Purser, The Search Conference.  The Publisher’s blurb about this book is actually quite accurate

Short guide to using Search conferences here

An article describing its use in food security

An article describing its (somewhat over-complicated) use in Northern Ireland

“Reviews and Commentary From The Publisher: The Search Conference is not just  another management tool, but a participative approach to planned change that engages the collective learning and creativity of large groups, inspiring people  to find common ground around new strategies, future directions, and joint actions. The process combines the best practices associated with strategic planning, systems thinking, and effective group communications – enabling participants to take part fully, rise above self-interest, and make decisions for the common good. Written by Search Conference pioneer Merrelyn Emery and Ronald Purser, this book uses a wealth of illustrative examples from a wide variety of nonprofit, business, and public organizations that attest to the  versatility of this important organization development intervention.”

And also there are times in public health when you can’t use a method quite at this level.

So here is the other method I use, the “Principles and Direction Sift”. Snappy title, I know, but it does have its uses.

The Public Health Principles and Direction Sift

This can be done in one meeting but often you get better results doing it over several sessions. It also seeks to be faithful to the scientific basis of public health and deal with the problem where evidence is lacking or silent. I’m not claiming this is perfect, but where I have used it it does work.

MEETING ONE

Step 1: Problem Statement

What, from a public health perspective, is the problem. E.G. epidemiology suggests there is no consistency of what follow up and support patients get after an NHS Health Check. Get everyone to state the problem, get them to agree the elements if need be and get a shared statement of the problem, challenge or issue. This could take 10 minutes or an hour. But get it out. It’s often good do to this as one meeting before you do the rest, and then everyone looks to find evidence and shares the evidence a week before the next meeting

If you are doing it in two meetings then at the start of the second meeting everyone needs to see and the group needs to revisit the problem statement.

MEETING TWO

Step 2: Evidence Assessment

Everyone reads and discusses the evidence and from the evidence identifies i) potential candidate interventions and solutions which have evidence behind them; ii) areas where evidence is not clear and iii) areas with no evidence. This could take between 15 minutes and an hour. But it should not dominate the session, the next stages are just as important.

Step 3: Evidence-current state fit

You group the interventions you currently have under which of the i), ii), iii) categories of evidence basis you agreed above, and if you need it a iv) category called “don’t know/uncertain/park”  What you should now have is a list of what you do with an idea of how they fit against the evidence. You will probably have at least some gaps where things you do have little evidence and where things with evidence are not being done well or at all.

Step 4: Principles and Priorities

Now you look back to the Step 1 problem statement and you compare the output from this with the output from Step 3.

You now need to work through and agree together an assessment of:

i) how well what you do now meets or addresses the problem and

ii) what principles (things like user acceptability, co-production, access) and

iii) which priorities (which bits of a strategy need doing first)

You are going to work on.

You will almost certainly have some stuff you are doing with evidence (and a pile of gaps) and some priorities you want to address with no evidence for what you can do about it.

For the former you need to ensure good implementation faithful to the evidence. Remember, implementation science suggests 30% of a programme’s value can be lost in poor implementation.

Step 4a: Navigating Uncertainty: Silence or Absence of Evidence

For the bits where there is no evidence, you cannot simply do nothing. You can either decide to do something pragmatic (which I would advise against unless that’s all there is you can do) or you can try to develop a logic model for some interventions where you can try to find evidence. A good way of doing this is to brainstorm from the principles those things which you think might be worth considering. Then you reality check them in the group.

When you have a list, you need public health and topic experts to search for evidence. If there is evidence you can apply it to commissioning interventions and go straight to Step 5 in the same meeting or another meeting.  If there is no evidence then use Step 4b.

MEETING THREE

Step 4b: Navigating Uncertainty: What is worth trying?

Public Health and topic experts should come to this with a worked up statement of evidence where it exists, and where there is no evidence some form of assessment of the ideas put forward and a theory-based assessment of what might work and a model of how to commission and evaluate it. This will need robust frameworks to evaluate and monitor whether it works so you can try it and if it doesn’t work decommission it. You need the group to agree a consensus around this before you go any further.

Let’s be clear what I have just suggested in the paragraph above. I am suggesting, and I am by no means the first to do this, the application of scientific method to the policy and commissioning process where evidence is silent or lacking. In other words, we would expect public health science to be busy creating evidence for us. But we can try to do this in a policy environment, and authors have put forward a variety of ways of doing this. Matrix RCL (who were major figures behind the Campbell Collaboration, the social welfare and social justice Answer to Cochrane) put forward just such a model for commissioners and policymakers in a briefing which has been widely used. You can access this briefing at http://www.jimmcmanus.info/Public-Health-Resources.html under the heading “Will this policy work?”

So an example: Imagine the evidence is silent on how brief interventions translate to behaviour change in primary care. So going back to theory of behaviour change we design a brief intervention for behaviour change using the methods which the theory of behaviour change suggests is salient, work it into an intervention, work up a framework to judge its worth and commission a pilot to see if it works.

I could spend the length of a book digressing here on the philosophical underpinnings of evidence-based practice and science. I will refrain for now. But I will point you to Nancy Cartwright’s lecture on the philosophy of science applied to policy problems ranging from Tamil Nadu to social welfare, which you can find here.  A thought provoking take, whether you agree with her or find it total madness.

MEETING TWO OR MEETING THREE IF YOU HAVE A THIRD MEETING

Step 5: System Check

You now check where you have got to. You should have a statement of what you are going to do. You now need to check that there is congruence between the problem, the evidence assessment and the identified interventions.

You can now start the phase of working up how you will implement all this.

This is not a rigid method. It works for some things and not others, but what it seeks to do is use a disposition to be evidence-led wherever possible and integrate that into how you build and commission programmes and systems.  It also seeks to deal with the fact that for much of health and social care, the evidence is absent.

“The Scientific Method”

The key point here is what would a scientific method suggest? That’s actually logically quite simple: read, hypothesise, experiment, evaluate and adapt consistent with the theory and evidence to date.

If the theory and evidence to date is right, you should eventually find something which works, because that’s how scientists do science in an academic environment. (And let’s remember the history of hunch, hypothesis, gut instinct and theory in science is actually a crucible of invention, not a pure process.)

If you don’t find something which works, then either i) you’re not following the method and theory properly, ii) not implementing it well, or iii) the theory and state of the knowledge is wrong. Humility, perhaps, and real life experience of how fragmented our systems are would suggest much of the time the answer is i) or ii)!

A framework for public health problem solving in the new world

 

A  Framework for Public Health “Consultancy” and Problem-Solving Skills: Using Mike Cope’s Seven C’s of Consulting in a Public Health Context

 

I have been using Mike Cope’s book “The Seven Cs of Consulting” for more years than I care to remember, at least since around 2001 when a first edition was published.

This short guide is intended to be used as a “quick guide” to applying Mike Cope’s book and learning from it in a public health context.  This book is well worth using and reading with a public health eye.

The Book: Mike Cope, The Seven C’s of Consulting

  • Paperback: 400 pages
  • Publisher: Financial Times/ Prentice Hall; 3 edition (22 April 2010)
  • Language: English
  • ISBN-10: 0273731084
  • ISBN-13: 978-0273731085

Why use a Consulting approach?

Public Health in the new system post April 2013 needs to work with a range of partners, applying their expertise and skills, to improve and protect the health of the population. We should treat our partners as “customers” – people who want or need something from us and have asked us to help, and for whom we should seek to provide a high-quality process and product or service.

This means we  could and should work almost like problem-solving consultant, working with CCGs, Joint Commissioning Team, other HCC Departments, partners and others, where we seek:

  • to identify the problem or challenge and agree with the ““customer”” (our partner/CCG etc)
  • identify what public health skills, support, advice and engagement will be needed
  • deliver this
  • close the piece of work

Anyone who has done consulting or indeed public health – short term or long term – would have at some stage experienced that they are expected to do nothing less than magic. There are many schools of thought on problem solving success – ranging from following of rigid methodologies and templates to the other extreme of letting the consultant on the job doing it in their own individual style.

What this book offers is a model – “customer”, clarify, create, change, confirm, continue, close” – that serves as a framework for handling problem solving and support work and this can be applied to situations where “experts” in a technical field use their skills to apply to a specific challenge. In addition to providing a professional touch to the consultant, it also includes “customer” in its approach aimed at bringing out the real problems (and not just perceptions) and the long term solutions.

I have used this approach since the first edition of this book in 2001. What it does is offer an effective process to understand the person you are working with, clarify what needs to be done, deliver it and close off.

Each of these 7C’s in-turn has seven steps – so this is really about “49 steps to effective problem solving” – making it really comprehensive. You may not need to use all 49; as long as you get the seven steps clear and the key outcome for each, you can get a good process.

Each of the seven Cs are shown below. You might find this helpful when working through the book, and the book is well worth getting.

The Five “Es” of Public Health

Public Health is about achieving the 5 E’s as part of achieving the improvement and protection of the health of our population:

  • Evidence – application of evidence across the commissioning and provision of services to ensure
  • Equity across populations
  • Effectiveness of interventions
  • Economy for the public purse
  • Efficiency in commissioning and provision

This means we need to use technical public health skills with a range of stakeholders, across a range of problems. We seek to problem solve and improve. Treating people as customers can work for us. Finding an approach to problem solving and embedding solutions also can work for us.  There are real similarities between this process and the business consulting process.

The Seven Cs Process has a number of assets about it which can help us work effectively in delivering public health solutions.

 

Now onto each C in turn:

1.“Customer” – Getting it Right from the Start

The key insights here are that applying public health skills is a social/interpersonal act. You need to build a relationship where the person you are seeking to support is clear what they want, need and are getting out of you

Cope says there are 7 sub-steps to doing this well:

  • Orientation – Viewing the problem as the “customer” sees it (including their perception)
  • Desired Outcome – Bringing clarity of the desired outcome (the real value and not just an end-state) and getting this agreed in writing
  • Change Ladder – Removing the fog from the problem by focusing on where change may be required using public health skills
  • Situation Viability – Studying if the issue can be successfully resolved and see if the timing is right for change
  • Decision Makers – Having a clear picture of the decision makers who can influence the initial stages of contract development
  • Ethos – Considering if the changes will be coercive or participative in Nature.
  • Contract – Establishing a contract or work plan or Memorandum of Understanding that sets out a framework for action and measurement
    • In Public Health terms you could also consider the Public Health 5 Es here : Evidence, Effectiveness, Economy, Equity, Efficiency

Your key output is a statement of what the challenge is, and how you will work together to address the 5 public Health E’s

 

2.  Clarify – Understanding the Real Issues

The key insights here are, now you have an understanding of the “customer”, real clarity on what the issues are. Public Health is as much about asking the right questions (what need, what issue, what population, what outcome wanted, what evidence for interventions, what process to apply and what scale) as giving the right answers.

  • Diagnosis – Gathering information that will determine the real sources of the issue and not just the symptoms
  • Shadow – Getting a clear appreciation of the unspoken activities affecting the situation by speaking to and working with people
  • Culture – Understanding the deep cultural factors that might affect the change
  • System Construction – Understanding the structural make-up of the system
  • Stakeholders – Getting a clear map that indicates who can influence the outcome of the change
  • Life-cycle risk – Determining the extent to which known and unknown factors will have an impact
  • Feedback – Establishing clarity on how the “customer” and the organization wishes to be informed of the progress

 

The key output here is an understanding of the political, cultural, organizational and technical challenges and the process milestones which you can share confidently with the “customer” and enables you to practice both the science and the art (persuasion, leadership) of public health


 
3.  Create – Developing a Deliverable Solution

The key insights here are to develop a solution which is

1) either based on evidence or, where evidence is silent has a clear logic and theory model with evaluation framework which enables us to tell whether it has worked, and

 2) implementable and achievable within the context of the organization, finance, problem etc

  • Managed Creativity – Ensuring that any creative solutions can actually be delivered.
  • Creative Blockage – Understanding the potential creative blockages for the “customer”.
  • Scanning – Finding solutions in the evidence and in the work others have done or doing (not trying to re-invent the wheel) and using and assessing evidence for these solutions
  • Storyboard – Underlining a clear process for deciding on the final solution and how public health skills apply.
  • Resources – Mapping the resources needed and available to the potential solutions to ensure that the options are viable
  • Stream Owners – Identifying clear owners for the solution and verifying that they have the capability and desire to own them and identify who will do what and how
  • Positics – “Positive application of Politics!”. Considering if it is possible to redirect some of the selfish energy of internal politics and turn the negative aspects into worthy ones.

The key output here is a plan (some written, some perhaps best left to agreed unwritten tactics) of how to get to the desired outcome for the “customer”

 

4.  Change – Working to Make Things Happen

The key insight here is how to make the change you and the “customer” want to happen. Much of this will be down to them but you need to apply public health skills to guide them through the process and do the right thing consistent with steps 1-3.

  • Methodology -Understanding the ethos and approach of how the change will be managed
  • Energy – Appreciating where the change energy will come from, and how it could be neutralized or enhanced across the different stake holders and problems
  • Engage – Engaging the people to be involved in the transformation process at a personal and emotional level.
  • Entry – Identifying the best level of entry to make the long-lasting transformation on the change ladder
  • System Dynamics – Anticipating how the system would react to the proposed change
  • Uncertainty – Make the plan flexible enough to operate in a dynamic and complex world (predictability and stability are false idols!)
  • Resistance – Accepting resistance to change as expected and working towards minimizing the resistance to the proposed changes

The key outcome here is you and the “customer” working with your guidance and support, to deliver the change agreed in the steps above with your ongoing support and advice. This may mean:

  • Advising, sitting on project teams, delivering training, showing people how to apply the solution, advising on implementation, working through specifications for commissioning and commenting in detail etc

 

5.  Confirm – Measuring the Change

The key insight here is to confirm that the change is occurring or has occurred (e.g. the new pathway is getting in place and being embedded.)

  • Responsible – Agreeing upon who will own and manage the measurement process
  • Timing – Deciding when the measurement will take place (without which early results – which may not be true indicators – are taken to measure success)
  • Design – Identifying the qualitative and quantitative measures and establishing the relationship between these measures.
  • Depth – Determining if extrinsic measurement be used or to deal with intrinsic issues such as motivation, attitude and beliefs
  • Data map – Controlling measurement activities to ensure that an integrated approach is taken in the clarification stage (and not a deluge of data)
  • Consulting Performance – Gathering quick specific and detailed feedback of consultant (self) performance from the “customer”
  • Costs – Having a clear view of the impact cost will have on the different measurement processes

The key outcomes of this C are:

1)   A clear way of measuring and determining that the change desired to solve the problem has been achieved , and is agreed between “customer” and consultant AND

2)   Clarity on what has been achieved

 

6.  Continue – Make Sure that the Solution Sticks

The key insight here is to make sure that the new solution is embedded into practice/commissioning by the “customer”.

  • Sustainability – Planning to ensure that the change is sustained and ensure slippage doesn’t occur after the transformation project has been closed
  • Language – Determining the extent of the change by observing the shift in the “customer” or consumer language
  • Gravity – Ensuring that the weight and structure and bureaucracy of the organization doesn’t take away from the transformation
  • Flow – Gaining from change projects by way of learning and reflecting (equally important as the end delivery)
  • Knowledge TransferTransferring the knowledge and competencies so that they remain in the business
  • Knowledge ManagementWorking towards making knowledge created as part of the change be embodied as a tangible asset to the business
  • Diffusion Channels – Analyzing the “customer”’s capability to physically diffuse new ideas through various channels

The key outcome here is to ensure that your solution works for the client and works for the 5 Es of Public Health


 
7.  Close – Signing Off with Style

The key insight here is to ensure that you and the “customer” agree the piece of work has been achieved, and you can move onto the next piece of work/challenge

  • “customer”s view – Listening and taking time to understand the “customer” perception over the total life cycle of change
  • Outcome Review – Pulling together data and gauging the the success of the programme
  • Learning – Help the “customer” to consider what has been learned over and above the planned outcomes
  • Added Value – Checking if there is clear indication of a tangible improvement to the operational or commercial viability of the organization
  • Build – Investigate what opportunities exist for future work
  • Reengage – In this closing stage, there are multiple options to re-engage with the “customer” on what further needs exist for public health input. Key ones are re-engage and modify (if parts of the process has failed), re-engage and extend, close and exit (with a feel-good factor), close and start a new engagement (an ideal outcome).
  • Exit – Ensuring that unnecessary levels of dependence have gone from all sides of the relationship

The key outcome of this stage is a “customer” who is clear what has been achieved, what they will do now, and what, if any, our role is for them .

Mike Cope’s books have helped me greatly in my professional and volunteering life. I am currently working with colleagues on applying these insights at work. If you want to use this, buy the book and let me know how you go.

 

Self management in chronic disease: yes, we can?

I was privileged on Thursday this week to be part of a (very large ) event run by Herts Valleys Clinical Commissioning Group, on their commissioning strategy, one of a series of events the CCG is running to get their strategy right. And I have to say, the passion and engagement in the room from several hundred people (we were in a big venue, and it was jam-packed solid) was palpable.

We got talking in the workstream on Older People and Complex Care, led by Dr Anne-Marie Essam, about self management and about the possible role of the behavioural sciences. A lot of work on self-management nationally and internationally has not delivered for a range of reasons. Yet Diabetes UK, Macmillan Cancer and even the early 1990s work on self-management for people with HIV by the US National Association of Social Workers demonstrates that it can be done and can work.

This tempts us to put self-management into the too difficult box, like the sigh and slump of shoulders when we read yet another study about an intervention not keeping people out of hospital.

Anne-Marie asked me to give a psychology/behavioural science geek take on self-management and why we seem to get it wrong. So here goes.

Self Management – aspiration and theory

Self-Management in chronic disease is a policy aspiration partly driven by experience of some people with some conditions (self-management in Diabetes) and by theory. So we have a policy chasing evidence. There’s nothing wrong in this, providing that the theory and concepts of self-management were rigorously designed consistent with best theory and evidence.  But a lot of research studies have suggested that where we are trying self-management, it’s not doing brilliantly well in practice.

But it remains good theory that people should be able to manage themselves, with help and support and skills, to remain as well and independent as possible, for as long as possible. And an ethical principle is that we have a duty to ourselves and to others to exercise some form of stewardship over our own lives, as long as we are able to.

A concept which heavily influenced me early in my career was that of the productive living strategy for people with chronic disease. Don’t talk about self-management if you can’t find a strategy and goals for people where they feel their lives are productive and valuable.  Jerry Johnson and Michael Pizzi wrote a book in 1990 on Productive Living Strategies for People with HIV/AIDS which was the right book at the right time, but now seems sadly out of print. This insight and concept is woefully underused still.

What’s wrong with the evidence, then?

Well, there’s nothing wrong with the evidence that shows self-management isn’t working well, except perhaps that most of these studies rely too heavily on one set of methods (quantitative OR qualitative) and so we don’t get a rounded and nuanced view of some of the issues. Human behaviour is complex, and as such it often needs to be researched in a way which understands that complexity. Qualitative AND quantitative methods are both needed.  Many studies point out there is a problem with implementing interventions consistently and well, and this in itself can confound any good study of whether the theory of self management actually works. Indeed, one of the insights of  Implementation Science is that implementation is every bit as important as evidence. Self-management is complex because human life is; so the reasons it fails are often equally as complex.

But there are many examples of patients who self-manage well. So what’s the issue we need to solve?

Needless complexity

Well, it might be that we are making things needlessly complex in two ways:

  • First, we over-complicate the theory and the interventions
  • Second, our complex health and social care system complicates things

Complex (many variables in an issue like self-management) doesn’t need to be complicated. That’s at least one area where we fall down.

A very recent paper in BMC Health Services Research is the latest in a line of research which suggests a number of issues with self-management. I am going to summarise these and several other papers. At least some of the reasons self-management fails to deliver are:

  1. We complicate needlessly
  2. The aspiration for self-management is good but it’s badly designed from the start
  3. providers and clinicians may not have time or skills to do it
  4. We don’t have good enough frameworks to understand what makes a person able to self-manage and what can enhance this
  5. The interventions we design to help people self-manage are sometimes overly difficult to access or put too many demands on peoples’ lives. For example, self management courses DAFNE and DESMOND for Diabetes have good evidence, but in their early forms taking a week to attend a class if you’re working is impossible for some people. And for some patients this is demotivating.  So we use a sledgehammer for a big blow when taking it more slowly might work just as well. Contrast this with the highly successful newly diagnosed with HIV courses running in a variety of places including Saturday Mornings. You can’t tell me HIV is less complex than Diabetes. This leads to another problem
  6. We sometimes stick to the evidence like glue “Only DAFNE works and you must attend it all week” when the obstacles to implementing this and difficulties for patients in achieving it actually demotivates and disengages patients. As professionals we need a more mature approach to evidence based praxis
  7. We often don’t use insights from behavioural science or health psychology in designing and implementing interventions
  8. Our clinical pathways, IT systems and financial incentives aren’t designed to make self-management work
  9. Patient-professional communications, as health psychology has shown, can often derail any well-intentioned attempt at self-management
  10. Peer support is often lacking or minimal
  11. Don’t reinforce the desire for self-management across all contacts with a patient
  12. A lot of research on self-management  and protocols for doing self-management are still using paradigms which are more biomedical than behavioural
  13. We don’t get blended learning well. I’m taking HIV again as an example because there is so much richness to learn from this field. Adults learn in a variety of ways. Combining easy to access support with information and tips and seeing it in practice works well. Check out how MyHIV has done it. It looks like it was designed using adult blended learning and empowerment theories. It clearly works for some people very well.

That’s enough to be going on with and if you’re like me you’re now being tempted to groan with despair.

So how do we understand the problem?

As a psychologist by training, one of my disciplines is when the evidence is not promising or silent, to go back to theory  and seek to test it by rigorous design of implementation frameworks and equally rigorous evaluation. In Health Psychology there is a tool called Implementation Mapping , developed by Bartholomew and Kok in the Netherlands, to help you do just this. Their book is still in print and extremely useful.

When an intervention isn’t working in the way the theory suggests it should, there are several possible solutions

  1. The theory of self-management is bad and should be ditched (I don’t think
  2. We’ve got the wrong concepts, frameworks and strategies (I think this is what the research is saying)
  3. We implement it really badly (I think this is also what the research is saying)

Let’s be honest, self-management is a complex intervention (by which I mean it has multiple components, not that it’s rocket science) which requires a framework, training, skill and expectations for everyone. Can we hand on heart say we have done this?  I doubt it.

So what, if anything, can we actually do?

Allow me to bang the drum for psychology here by saying NHS and Social Care Commissioners should have access to a well trained behavioural scientist who gets the real world and helps design interventions and their training which works and spends at least half their time on this. An investment of £70,000 a year in behavioural science could help.

But in a regime of austerity this might be a step too far if people feel behavioural science is unproven. So let me suggest  a process for getting self-management right

At Strategy and Commissioning Level

  1. Get a small action learning set of interested people together. Patients and Carers who self-manage well should be part of this and a behavioural scientist or psychologist
  2. Review the evidence and literature together using a workshop approach so everyone understands it
  3. Come up with a framework for self-management together
  4. Test it to destruction by throwing every possible problem and bad management event at it
  5. Make sure it becomes everybody’s business and that everyone has a role and has appropriate training to support self-management
  6. Redesign the system of going into and out of hospital so it supports self-management for those capable of doing it
  7. Design and run better, more real world, self-management courses for patients
  8. Integrate qualitative data from patient experience into design of systems. There are ways of testing and assessing qualitative data.

At Clinician Level

Let’s be honest here, only partnership with patients and carers will help us get self-management right. I learned valuable lessons about self-management from the way my mum and dad managed their disability and heart disease respectively which helped me understand the theory and evidence better. There’s nothing wrong with clinicians using and reflecting on patient experience to dialogue with the theory and evidence. We should encourage it. Reflective real world practice is often referred to in social sciences as praxis – (not the Marxist sense of the word) but practice informed by theory and evidence and reflection on that.

So supporting praxis which understands the insights from behavioural sciences about self-management is crucial. One of the best ways of doing that is build workshops where patients and behavioural scientists and clinicians can share and reflect.

At Patient Level

The first thing to do is not start building unnecessarily complicated interventions. If you have ever heard of the Di Clemente and Prochaska states of change model for health behaviour, now is the time to  park it somewhere nicely for the duration of this project. It won’t work in this situation and was arguably never intended to be a theory or model for behaviour change anyway. Yes, it works in some situations, but actually has major limitations.

Susan Michie has proposed a behaviour change model which is actually more simple, well grounded in theory and supported by evidence. And it is this:

  • For most health interventions, capability plus motivation plus opportunity leads to behaviour.
  • This needs skills, support and reinforcement

She talks of the Behaviour Change Wheel and you can find two free papers here:

If we follow Michie (and a host of others) then there are two big tasks for us :

  1. at patient level we need to assess, build and constantly reinforce the person’s capability, motivation and opportunity to self-manage. Capability includes the skills to do it and also the belief they can do it, as well as the readiness. In other words, interventions which support and train and reinforce and motivate are more likely to show effect if they are consistent across someone’s encounters with people and the person believes they can do it. Some folk will never manage it (they will always need it done for them), others can and do everyday.
  2. That brings me to the second, we need a behavioural science approach to understanding how we turn those who can’t into those who could.

Study after study suggests to us that self-management is difficult. That doesn’t mean it’s impossible. If we make it work, the benefits to patients (better quality of life), to NHS and Social Care (less cost) and to everyone (people with chronic disease able to live well with dignity) are clear. The problems are we use the wrong models, implement them badly and assume it’s either too easy or too difficult.

Who’s up for trying?

Helping community agencies be effective in community safety and public health

 

To support agencies wanting to bid for the  fund for communities created by Hertfordshire’s Police and Crime Commissioner I found and shared a set of resources and tools which people might find useful.  I shared these on twitter and lots of people came back and asked for more resources.

So  here, in one place, are a range of tools and resources for you to use and share.

A good place to start is reading the Hertfordshire Police and Crime Plan.

 

Evidence for what might work in crime reduction and community safety

There is a lot of opinion about what works and what doesn’t in crime reduction. I am going to point you to the resources which I and colleagues have found to be most rigorous

  • The Campbell Collaboration has a host of systematic reviews on crime and social issues
  • A Knowledge hub of a range of things which work is here
  • Thinking of doing something on fear of crime, try here or here
  • Reducing youth crime and anti-social behaviour: a useful resource is here
  • If you want to train up community practitioners, you might find some training models here for crime reduction and here  and remember Neighbourhood Watch do a programme of training for community advocates
  • Publications by Jim McManus on crime reduction and community safety including hate crime and designing out crime are here

 

Networking and support for agencies working to reduce crime

  • CLINKS helps voluntary and community agencies who work in reducing crime and re-offending

 

Understanding Health Inequalities, guides for community agencies

  • The Royal College of Nursing has a really useful webpage and guide

 

How on earth do I evaluate and monitor whether this works?

Evaluating (i.e. finding what the impact of your intervention was and whether it’s worth it) is very important because we need to know whether projects work, do nothing, or do harm. Community agencies so often find evaluation a world where experts talk jargon at each other. Here are my top resources for communities wanting to evaluate:

  • A very simple, straightforward and easy menu of tools for evaluation and monitoring aimed at not for profit and community agencies is here.
  • If you need to get your head round what evaluation is and why you need to do it, Evaluation Support Scotland has some excellent resources
  • The Kellogg Foundation Handbook is free and one of the best whole system approaches to evaluation you can find. This provides a tried and tested model used in major and minor projects in developing countries. I have used it and it works.
  • If that’s too ambitious you can try Charities Evaluation Services who have a range of tools on evaluation
  • Prove and Improve is an online toolkit to help you demonstrate projects work and improve their quality and impact

 

What about attempting a cost-benefit analysis?

The Office of Public Management has a really useful tool, Valuing Public Services on how to measure the value of services and interventions

 

And finally…

Can you explain something in plain English rather than Jargon?  (Ok, yes I fail often at this.) Try this tool http://www.splasho.com/upgoer5/

 

If there is stuff you want but isn’t here, tweet me @jimmcmanusph or email publichealth @ herfordshire.gov.uk  with “Ask Jim” in the title

What can a Public Health mindset bring to making communities safer?

Hertfordshire’s Police and Crime Commissioner has done something visionary.  He has set up a fund for communities to put together “innovative local schemes which aim to make our communities safer”. This fund is linked to the Police and Crime Plan for Hertfordshire, which takes an “everybody’s business” approach to reducing crime and making communities safer.

Less than an hour later I had tweets and emails asking me what evidence communities could use. Then people started asking me how they could develop and put evaluation frameworks around bids. Then partners asked – can we use the Herts Public Health Partnership Fund given to LSPs and Districts to match fund where there are clear links and overlaps? (The overwhelming view of the Public Health Board was yes.)

This set me thinking, what does Public Health have to bring to the table?  More years ago than I care to remember, I produced briefings on crime and community safety among other work I did in community safety and crime reduction. My public health training helped me find the evidence and organise it into tools which went to statutory crime and disorder reduction partnerships.

I often say one of the ways I describe Public Health  about four Ps:

  • A Perspective (or Mindset) which focuses on
  • Populations and sub-populations; which is
  • Prospective (it looks to what can be improved, prevented or avoided) and goes retrospective to understand where we are today
  • Protective – seeking to protect communities and individuals from risk to health and life

The mindset of Community Safety is very similar. Both Public Health and Community Safety work in similar ways: through communities, through skilling people up, commissioning and using interventions which have evidence of effectiveness and sometimes, when the evidence is silent, going back to good theory to build an intervention and evaluate whether it works.

The Evidence

Crime impacts on Health in a range of ways, and there is a great deal of literature on this. Things like acquisitive crime to feed drug habits, and the devastation of domestic violence and hate crime are perhaps the ones that spring readily to mind. But there are other issues too:

  1. Evidence suggests that ongoing stress from high levels of crime and high fear of crime contributes to a stress pathway that can lead to mental ill-health, poor resilience and even heart disease and stroke.
  2. Victims of crime are more prone to physical and psychological ill-health on an ongoing basis.
  3. Disabled people are typically more victimised for property crime than the general population
  4. Hate Crimes have enduring mental health consequences
  5. Victims of violence often develop adverse coping mechanisms which develop health problems
  6. Ongoing phantom pain and unexplained symptoms among people who are victims are not uncommon

By contrast, communities which have strong self-efficacy (i.e. they believe they can do what they need to) are more resilient (i.e. they can handle challenges and problems more easily and return to a good state of functioning more readily), healthier and more able to address issues of relevance to their communities like crime and disorder. They also have lower fear of crime.

Building resilient communities

So how do we build resilient communities? In essence where people share the same place and public realm we need to support communities find strengths, self-confidence, skills and solutions at individual and interpersonal level, have strong links with each other and develop a sense of affinity for those they live next to and nearby.   Where people share the same identity (sexuality, faith, nationality) finding common ground and sharing common interests are salient. This is neither new nor rocket science.

But often we lack the insight of the behavioural sciences. And it can be quite simple to harness these. We talk about community development in the UK. In the US they talk about Community Advocacy. Community Advocacy has at its hear building capacity in communities to help themselves, to do, to believe in themselves. The approach works in Community Safety as well as Health.  It is particularly effective for marginalised communities and those experiencing hate crimes and has a strong track record in the US. The role of a range of diversity groups  such as Faith Communities in Health Advocacy in the US is particularly striking, working as they do for very marginalised communities. We have much to learn from them.

Building resilient communities is something which public health and community safety could do together, because everyone benefits. Addressing specific types of crime (hate crime, domestic violence) also brings ongoing benefits to both agendas.

The Public Health Contribution

Taking just the range of issues above, Public Health has a lot to bring to the table. The prestigious John Jay College of Criminal Justice actually has a whole programme of courses on health and crime.  I am going to list just some of the things public health can bring to the table:

  1. Sharing epidemiological skills so we can understand better the distribution of crime in time and place
  2. Working together on public resilience and mental health agendas
  3. Finding and appraising evidence for effective interventions (see my next blog post)
  4. Helping NHS commissioners and providers respond early and effectively to victims of crime
  5. Training Police and others in preventing victims of hate crime becoming more traumatised
  6. Providing drug and alcohol services and pathways which cut crime and disorder and help people with problems
  7. Providing training to communities who want to implement and evaluate programmes
  8. Sharing evaluation, evidence appraisal and policy appraisal skills with people in crime reduction
  9. Ensuring services for those likely to become victims of hate crime encourage and support people to report
  10. Ensure the cycle of crime in troubled families is broken by finding effective interventions for people to thrive
  11. Find interventions which help children thrive emotionally and value themselves and others
  12. Using the public health role in licensing to the best good of communities

The new landscape of the NHS means NHS Clinical Commissioning Groups are responsible authorities for Community Safety Partnerships. This could be seen as yet another burden on new CCGs. The challenge is to find ways of integrating the CCG agendas with the community safety agenda, and picking some concrete issues and projects to start with.

My next blog post will do two things: signpost agencies to sources of good evidence in crime reduction, and signpost them to resources to help them evaluate interve