Systems and Transformation for better population health: pointers on the journey



Earlier this week I had the privilege of participating in two sessions at the Public Health England 2017 juliaConference.  I took part in a Behavioural Sciences in public health session and in a Public Mental Health session. At both sessions the discussion, comments and questions from the audience were stimulating and deeply thoughtful.  In the public mental health session I came face to face with the strong realisation that I was in a – packed – room full of people all of whom were thinking about systems approaches.  I even asked if that was what we were doing and got enthusiastic nods and responses. What an experience!  Seriously, it was brilliant.

Anyway, lots of conversations ensued afterwards with people asking about systems. Now I have blogged before about whole systems approaches to mental health and about some of the leadership issues in leading across systems, and some of the problem solving approaches public health can use in a systems world.  You can’t do systems work on your own. And you need to be structured, purposeful but also opportunistic.  We should, as Public Health types, find a natural bent to this.

Top tips for system working

For me the key thing about a system is that every system is perfectly designed to produce what it produces. So if it’s dysfunctional, in what it produces, you are going to have to disrupt it.  And that takes planning, effort, and a coalition

This is an art not a science, so my top tips for systems working start with doing some reading on systems and then work with people who like working on system change.  Some resources you could use for systems thinking are:

There is also an online course in Systems Thinking for Public Health from Johns Hopkins. This will give you one take on systems thinking, because there are several takes on this concept.

The thing about a system is that systems science is not a complete explanation

Recognise though, that systems approaches often come from an engineering or management paradigm (many business schools grew out of engineering schools historically) that see systems as machines.  I think some of that is true, but for the most part systems are made up of humans so there are ALWAYS complex social processes and cultural issues at heart, and they explain behaviour of the system and the people AT LEAST as much as the processes in that system. So, if you don’t understand a system at least in part as a complex set of social processes, you are doomed to fail. So go beyond systems science before you go rushing in, because systems are actually not machines but complex social networks and processes.

Understanding complex social processes

You could do a lot worse that do some reading on changing cultures and complex social processes. My top reads would be:

  1. Wiggins  & Hunter. (2016). Relational Change: The Art and Practice of Changing Organizations. Bloomsbury
  2. Shaw (2002). Changing Conversations in Organizations: a complexity approach to change. Routledge.
  3. Ralph Stacey (2012) Tools and Techniques of Leadership and Management. Routledge
  4. Social Network Approaches to Leadership

A first key step is to try to understand the system, map it, understand it. Conceptualise it somehow. Then it’s vital to recognise that the system is made up of complex social processes, and you need to understand those to intervene, and you need to intervene in multiple places and do so purposively. Sometimes you just need to be opportunistic.

To intervene, you often need to disrupt the system, and that means getting a bunch of people to join you. Set some sensible system goals so you know how you’ll get there and when. Start somewhere, more or less anywhere, and start where you think you might get most output.  No, it’s not scientific in a positivistic way. Most systems don’t work and can’t be understood like that anyway.

Changing systems is a journey, expect it to take time.

Understand the failure points

We need to understand the lessons of failure of transformation. One of the best papers I ever read is John Kotter’s  “Leading Change: Why Transformation Efforts Fail” listed above.  Kotter talks about eight steps to transforming an organisation, and if you don’t do these, they are very strong predictors of failure.

I seriously recommend getting hold of this paper. It was published in the Harvard Business Review, originally January 1995 then reprinted in 2007 in BEST OF HBR.  This paper is so popular online that HBR doesn’t let you download or print it. I tracked down a paper copy through the British Library which is now much dog-eared and annotated. But it’s been worth every penny for me.  If you only ever read one paper on transformation, read this.

Kotter gives eight golden rules of what you need to do for successful transformation.  For me, these have been an excellent guide to any successful change exercise I have ever done. Not doing these are the eight reasons why transformations fail . These eight reasons are:

  1. Establishing a sense of urgency – you must identify potential crises and opportunities
  2. Form a powerful guiding coalition with enough power to lead change efforts and get them working together well
  3. Create a vision and develop strategies to achieve it
  4. Communicate the vision using every vehicle you can, use your guiding coalition to model the behaviours you want in the new world
  5. Empower others to act – get rid of obstacles and change this that undermine your vision
  6. Plan for , create and welcome Short-Term Wins and CELEBRATE them!  They are important milestones on the journey for morale, convincing people you can do it and get there and checking you’re still heading for target
  7. Consolidate your improvements and keep reinvigorating them. Do not declare victory too soon!
  8. Embed the new approaches and make sure people “get” the connections between them and success

This is not an exact science. But it is a combined exercise in conceptualising, designing interventions, problem solving and leading which will stretch, challenge, dismay and reward.