The Prevention Goal….will we ever get there?

We are in the middle of a winter crisis (again).  So why do I want to write about Prevention?  Well, history repeats itself usually because nobody listens or learns the first several times around.  And we still haven’t really learned as a system about doing prevention well. (Not for a minute am I criticizing some of the truly wonderful work going on.)

It does seem that in the last week, with the confirmation of ongoing cuts to the Public Health Budget in England and the lack of any really biting coherent prevention plans at national level for wherever the NHS is going now,  that we are about to experience what a colleague, Ben Bray, wittily and succinctly referred to as “a radical downgrade in prevention.” I’d love to say this insightful colleague is wrong. But the indicators suggest to me that in this year’s NHS he may very well be proven right.

Prevention – rhetoric rather than reality?

“Prevention” as a concept has become current, some might say “flavour of the month” in the public sector.

I could take a jaundiced view that we seem to be sliding into a paradoxical rhetoric on prevention nationally which is quite dangerous – being hailed as one of the tactics to deliver financial sustainability in a public sector despite the fact the proportion of GPD and public sector budget spent on it is declining, and fast[2] .

The really serious policy imperatives behind it are increasingly difficult to find, and the preventive power of really getting to grips with unwarranted variations in primary care remains – despite valiant work in many places – unrealized, with concomitant waste of money and avoidable morbidity.

One could also see there are more risks from policy assumptions being made around the current system change.  We assume that preventing high cost patients costing so much will bring major savings for nascent Accountable Care Systems/Organizations. But a very recent analysis in Health Affairs suggests this is not the case, and a more thoroughgoing approach to need and morbidity is needed.  We seem to be happy to take the rhetoric of Accountable Care Systems and Organisations without necessarily thinking through the reality.  Part of me wants to start a programme called “Brilliant Basics” where we focus down on the things we know will work rather than embrace yet more system change because someone somewhere has decided the current arrangements aren’t delivering.

Despite all of that, I am committed to making Prevention happen wherever I can. Time will prove me right or wrong.


Building a shared narrative with paucity of science and policy

Prevention means different things to different agencies. I think we should actually welcome this rather than getting precious about the body of “science” around prevention. Because to be honest, in some places, the “science” is pretty poor.  I think we need a paradigm shift in how we approach prevention scientifically – and the biomedical pyramid of evidence isn’t it.  For another time there is a detailed discussion of the evidential paradigms for all this, but I don’t have space here, and this is likely to be contentious.

What I have learned in listening to people this last year is that for some prevention is about preventing avoidable morbidity with its concomitant costs to peoples’ quality of life.  For others it’s about reducing and preventing waste from our increasingly throwaway society (the less sustainable we are as a society, the more it impacts the health of our biosphere and human health.)  The point is we’re trying to build an ethos across services of prevention.  Maybe we need a different word?  And maybe we need to be more pluralist around prevention, as long as we can deliver a “good” to the public.

Some fundamental questions of evidence and efficacy

But there are some fundamental questions we still have to address:

  • can we stop people needing services as much as possible in a way which gives value to citizens (not just financial value?)
  • Can we ensure people remain healthy and independent as long as possible?
  • Can we provide public services in a way which supports peoples’ independence as much as possible?

Prevention has been part of policy rhetoric since the Griffiths Review led to the 1990 NHS and Community Care Act (remember that, anyone?)   It’s time to look at what we’ve achieved and where next.  Public health people have a right to expect that government and other policy actors should take prevention seriously.  And everyone else has a right to expect from us that we have some evidence, pathways and principles of how we set about doing it.  For some things (eg hypertension, diabetes, HIV) we have the evidence and the pathways despite implementation being patchy.  For others (reducing hospital admissions) we have a long way to go and for yet other issues (public mental health) we have a long way to go to achieve the aspiration of getting our population resilient and healthy.

Trying to make it work: our local experience

Prevention forms a core part of the narrative around our Sustainability and Transformation Plans and those of many others [1] and is now also a part of the shared Hertfordshire Public Sector action plan across 30 organisations. Great. Policy commitment. Now what? Now the hard work really starts.

Locally, we’re currently working out what each agency will do.  We have some things working very well (I’m just going to pick out our Warmer Homes initiative and Social Prescribing, our Physical Activity work and embedding behaviour change into that, our bit of the National Diabetes Prevention Programme.)

We recognise we can’t cope with existing let alone projected demand. There is much more to be done through before we have a consistent view. A recent Prevention Summit[3] got over 100 agencies together and identified some shared priorities[4]. Stopping people from needing services, helping people stay as healthy and independent as possible, and helping people who need services recover as much function and independence as possible.

For the rest of the stuff I make no apologies that our run in to some of this will probably be eighteen months before we see tangible results, at least.  This is work in progress. Some of this may work, some of it will fail. But we have to find a way to deliver some value.

Some tasks

This raises several important questions for us . First, nobody seems to share the same idea of what prevention actually means (is it avoiding or delaying a need for a health or social care intervention? Or is it something else? Does it matter as long as the logic is clear and the intended outcomes evaluatable?) Second, what does quality look like in prevention? Third, how do we embed a culture of good quality prevention if we can’t agree what those things mean?

We do need to get prevention right, but at the same time we are at real risk of doing with Prevention what we often do with health and care policy.  we need to avoid making it the next panacea (remember Community Care? )  And what often happens is a new bright shiny thing emerges. It’s hailed to work. We find it doesn’t for the same reasons we always do, we decide it hasn’t worked and go down the road of structural change instead.  I can’t be the only one who things the new ACO/ACS combo is the next prelude to structural change in the NHS. And if these new organisms are to be effective, I think they need to work in a different way.  It will come as no surprise that I believe they really need to get to grips with systems and complexity approaches, but

Learning from Failure

We know enough from the literature and experience on health and care activities not working to know why things fail. Rarely is it down only to evidence of effectiveness…often it is down to the fact we don’t do it properly.

  1. We settle on a policy option without considering how it will work properly
  2. We decide on a national roll out or buzz word
  3. Guidance appears and is expected to be followed slavishly
  4. We don’t create the right plans or models for it to work
  5. We don’t put the right resourcing into it and we don’t implement systemically
  6. We still “do unto” patients rather than “work with” people
  7. We behave as if the system is a machine not something far more complex and so we take a linear “press a lever, it will happen” rather than a “this is complex change so let’s manage that well” approach to implementation
  8. We don’t give it long enough to embed
  9. We don’t consider the dependencies which will make it work better or worse (eg Adults with complex needs work won’t work without somehow addressing some of the huge constraints on housing supply. Very few of the existing models have really solved that problem.)
  10. We decide too early it hasn’t worked
  11. We quietly sideline it

It will be a great shame if we do this to prevention. And some of the signs are this is where we are going.  I predict also, though, that in two years time we may well be saying ACOs haven’t delivered on reducing costs in complex high cost patients to the extent we wanted.

I believe if we don’t tackle this issue as a system problem starting with culture and language, and prioritising some areas for action, our recourse will be further rounds of restructuring and cuts as the only option for financial sustainability.  Moreover, if we can’t agree what we want as a system, then implementation will not happen , and neither STPs nor healthcare will achieve their must dos, let alone the rest of the public sector.










Warmer Sustainable Homes, Healthier People

Today we launch another initiative in our work on Healthier and Sustainable Places.

A new scheme that provides free or discounted household improvements to help residents stay warm in their homes has been launched by Hertfordshire County Council in partnership with all 10 district and borough councils.

In Hertfordshire, over 32,000 households are estimated to live in fuel poverty meaning they do not have enough money to adequately heat their home. Colder temperatures can lead to excess winter deaths. Between August 2013 and July 2016, there were 1795 excess winter deaths in Hertfordshire. The Hertfordshire Warmer Homes scheme aims to make homes easier and cheaper to heat by offering free or discounted energy efficiency measures, such as insulation and heating repair, or fuel switching advice to low-income and vulnerable households.

The World Health Organisation recommends that homes should be heated to 21°C (70°F) during the day and 18°C (64°F) at night.  This is especially important for those with a young family, the over 75s or those with a long-term health condition, such as respiratory or cardiovascular disease.

The Hertfordshire Warmer Homes scheme will be managed by the National Energy Foundation, using funding from the national Energy Company Obligation (ECO) and local authority contributions. It will run to 31 October 2018.

If you know of people who would benefit from this in Hertfordshire, please help us raise awareness of this scheme by publicising it through your own channels.  Anyone can find out more information by contacting HertsHelp on: 0300 123 4044 (local rate) or You can find out more on our Warmer Homes pages.

Further information and a communications toolkit to help publicise the campaign is available on the Health in Herts professionals pages

Systems leadership, complexity and the public sector

I have the privilege of co-presenting a webinar tomorrow (2nd November 2017) with Harry Rutter on complex systems approaches in public health, organised and convened by the Health Foundation. You can find more details here and my slides for the event can be found here.  What I intend to do in the time available is basically spell out what I think complex systems approaches can do in Public Health, and my journey, with colleagues, in applying them.

I’m not claiming this approach is better than others, or that I am an expert, but I am claiming they have value. And I intend to give practical examples, and share what I have learned.

Systems Approaches in Public Health

A group of us have come together to produce a website and blogspot on Systems Approaches in Public Health.  The intention here is to provide practical resources and materials for people in public health as a starter place. We also want to encourage you to write for this and share your experience and issues.

The growth of systems thinking

It may just be me but in more places I look I see people considering systems approaches.  I had a meeting today with police colleagues on how we identify opportunities to prevent crises for people with mental health issues, and found the senior police colleagues in the room taking a systems approach, explicitly.  Yesterday I had a meeting with six elected members across three different portfolios and officers from each of them where we all, explicitly, adopted a systems approach to the issue of air quality.  I see more people applying this.

To be honest, I see systems approaches as another set of very useful tools in my toolbag. They are both a technical tool and a leadership opportunity.  I feel the same way about quality improvement methods, and the Generation Q Fellowship the Health Foundation has kindly given me, combined with what I am learning at Ashridge, is stuff I constantly can see applications for.

The Danger and the opportunity

The great danger of the rush to systems thinking is it becomes a superficial fad, and even worse, that Public Health somehow thinks it invented this. We need to guard against this.  The opportunity is that systems approaches reflect the reality of the world we work in better, and can make us more effective. Diverse people and players can, if brought together effectively, have an impact on issues which are complex in their nature, made more complex by the often still to siloed nature of the public sector.  Don’t get me wrong, I love the public sector, but we need to continue to strive to find new ways.

I look at my core public health colleagues working on tobacco control, on young peoples’ health, on suicide prevention and on environment and planning just as examples, and each of them is using a systems approach.  For me this is a hallmark of their effectiveness.

The attributes of leading in systems

Finally, over the last few weeks I have spent time with a number of our graduate trainees in local government. This is a band of people who are fairly fresh to local government, passionate about public service (which frankly makes me love being around them) and passionate about value for money and value for people. It’s a joy, a challenge and a privilege working with this bunch.  They energise, challenge, critique and roll their sleeves up.

In one series of conversations we were talking about the fact a few of them feel the public sector has great things but could be much better.  My view is “hold onto that instinct, trust it and let it energise you.”  This got us musing on the attributes of effective public leadership in the future.  On 14th November I will be spending time working on leadership with people already in the system seeking to achieve registration as public health practitioners.

What I’ve learned from all this, and what I’ll be reflecting on 14th, is that the leadership challenge is changing rapidly at present.  I think the world we are in needs  five hallmarks or attributes of public leaders for the future, who can work effectively in systems.  And here they are:

  1. The leader has a value base of service (the moral purpose of public service)
  2. The leader has a hunger for better outcomes, better value, better equity  (what’s the point otherwise?  Isn’t that why we all joined public health?)
  3. The leader has a preventive mindset – can think and deliver on how we keep people as healthy and independent as possible.  I would argue not only is there a moral need to do this but an economic case too.
  4. The leader has a systems mindset – can apply systems thinking effectively, with purpose and outcomes
  5. The leader is comfortable and adept at leading across distributed and sometimes chaotic systems. The leader as part of this can orchestrate a range of disparate and diverse contributions to a shared purpose with benefit for all – from siloes to symphony.

I could add a sixth, which is sometime the leader needs to disrupt where things are really dysfunctional.

The challenge

This is probably hopelessly optimistic for some of you. And indeed this is no small ask, is it?  But it’s what I want to try to achieve.

I think it’s where the policy environment and fiscal climate is leading us.  We are in a place in the UK public sector where national policy and the financial climate make realisation of local ambitions for our residents seem an almost impossible dream.  It feels like a perfect storm, and counsels of despair are ever greater from many corners. The great temptation is to give up or hunker down and weather the storm in our siloes until things blow over.  That seems a deceptively easy-looking option. And it’s the wrong one.

The challenge is to find a way of doing what we can to address ever more complex problems – mental health at population level, for example – and to do this with decreasing funding.

I believe working in a systems way, and working in the ways I have described above, are a promising way forward to weather the storm.  We’ll see whether or not I’m right.

Anyway, we’ll see what tomorrow’s webinar brings!

Readings for a new #publichealth councillor

Over the past few weeks, as the local government year starts to ramp up, a number of newly elected councillors have asked me for some basic reading on Public Health.  This is my suggested list for them.  Perhaps you could suggest some?


Dear Councillor,

Here is as  promised at the induction seminar the self-reading guide to getting your head round public health. There are many more topics than those below, and I merely set out some of the more important. Perhaps the best thing is to come and talk and if you want material on specific issues like drugs, or children and young people, I will supply you with a list.

Public Health principles: the very basics

Public Health is about working with populations, out of a framework of analysis, evidence and an intention to promote and protect their health. This involves working with a range of determinants of health from education levels to health behaviours and the various threats and hazards to our health which arise from the environment (naturally occurring diseases) and from the products and progress of contemporary society (air pollution for example). Poverty and inequity lurk behind most poor health like an eminence grise et horrible.  In my own mind, neither individual nor societal explanations for the burden of disease and ill-health and poor flourishing our society carries are sufficient. Both must be held in dynamic tension to elucidate what the issue is and what we can do.  Equally, Public Health is not, to me, purely a science. It is an application of various sciences and art.   Epidemiology and Leadership, Evidence and Influencing come together or lie ineffective. They are a blend, if you will.

We now have three out of 6 short e-learning video presentations on what public health is on Herts Health Evidence and more will be added soon.  You should be able to access these free by requesting an account at the site.

The Open University has a variety of free online courses here

If you wanted a book, then my best bet to start would be Virginia Berridge’s Public Health: A Very Short Introduction Oxford University Press, 2016. Let me know if you have difficulty finding this, I can track it down easily in London next time I’m there. There are many more choices after that from classics like Donaldson and Donaldson’s essential public health through to Geraint Lewis’ Mastering Public Health which is to my mind far more useful than Donaldson and Donaldson.

English Policy on Public Health and NHS (because Wales, Scotland and Northern Ireland all have very different systems.)

This is invaluable

The easy read on the last seven years of policy history (about which I could talk without cease and without notes) is this from the Kings Fund and this set of videos . A further read is here

I think you can trust the King’s Fund an independent health think tank. It’s well respected

Responsibilities of Local Authorities

In terms of the key Public Health Responsibilities in local government, the choices are endless so I would go for the list below

  1. The basic guidance (there is an awful lot more)
  2. The Local Government Association publications are always extremely valuable and I suggest these two as starters

But there are many more from the LGA, and the LGA website has an invaluable series of publications for local authorities on public health.  I am of course biased but the Association of Directors of Public Health blog has a series of very short pieces. and it’s worth checking our updates here

Mental Health

The Local Government Mental Health Challenge website is a very useful starting place to some of the issues  I find this guide on system wide (population or public health approaches to mental health) commissioning principles useful  and Finally, the Mental Health Foundation’s report is very good

Health Inequalities

The Marmot Report is probably the best starting place but there is also a social sciences answer to it too, which makes specific policy proposals, some of which we have adopted in Herts

The NHS Sustainability and Transformation Plans

I would look no further than the reports from The King’s Fund

I suggest pick these and come and have a coffee and ask any question you like, or we can even do a seminar for your group or whoever.

Happy reading.  I should finish on one note. If you are confused, then you join the rest of us. If it all makes perfect sense, then you really have missed at least one important thing.




Not another video about HIV? Yes! Here’s why.


In less than a month, on 11th October 2017, a new and I think ground-breaking resource will be launched which tells the story of people living with and affected by HIV.

What, another one?  I hear some of you ask.  Yes, and I’ll tell you why.

Why another resource?

This resource is different. Funded by Public Health England, through their HIV Prevention Innovation Fund, this new resource will feature people prepared to talk despite the stigma.  It privileges the voices of people living with and affected by HIV above other voices. Multiple people living with HIV and affected by it are in the resource, have co-produced the resource and have been in workshops considering, commenting on, augmenting and amending the resource. This has been, in and of itself, a powerful experience.

This resource has a series of videos, accompanied by a website of resources, blogs and other materials. It features people with HIV prepared to share how they thrive, cope and how HIV, their health and the deepest issues of their lives come together, and the problems and the positives of that.

And I have been privileged to be the sponsor of that project, at PHE’s request.

This will be a tool to combat stigma.  It will be a tool to show people the nuanced reality of living with HIV. It is a tool for people with and affected by HIV.  And it is a tool for celebrating people with and affected by HIV.

The changing nature of life with HIV


We are in a time when virological suppression is a major success story (People I work with, people I love who ten years ago would have died are still alive and well and every day I cherish that and them.)

We are in a time when we could achieve the end of new HIV transmissions, and tools like PrEP are further resources in the long travail which has been the journey since the first people I knew and loved with HIV died. Today, many people with HIV are thriving , some in jobs vital to our society, others quietly living and working and relating, living out their gifts and their talents.

But, others still aren’t thriving. And it’s not just about biology. Far from it. With the success of virological suppression – where the virus is essentially regarded as undetectable – come a range of opportunities, choices and still many challenges. Stigma, ongoing challenges of living, new health threats to people with HIV, and the need to renew our efforts to cherish those with and affected by HIV while reducing new infections.

People live longer, they contribute their talents and gifts to their loved ones and our society.  Great.   For some, cognitive decline, however subtle, diseases of ageing in an ageing cohort of people with HIV, negotiating social support, relationships and just coping with life alongside a lifelong health condition, remain psychological, social, practical and – dare I say it – spiritual and existential challenges.

Negotiating life with HIV still takes skill. For every person who accomplishes it with panache, there is a story of sheer hard work behind it.

In a world where Pre exposure prophylaxis is becoming more available (though I notice our trial in England is still dragging its heels) and undetectable status means different issues for negotiating intimate relationships than it once did, we need more than ever to reaffirm people, reduce stigma, and most of all, learn from our friends, colleagues, loved ones, partners and residents with HIV.  One of the world’s foremost HIV resources, Aidsmap has a great post on why it endorses the prevention access statement for HIV which makes you realise just how much has changed, and how much we still have to achieve.



So come on, what’s special about this, really?

Well, two things.  First, the people in it.  Secondly, the people in this resource, and the resource itself, will address HIV through the context of Faith. Specifically, Christian faith in this resource, but other faiths may follow suit.

I want to tell you why, and why health professionals should take notice.

But let me say this first: this resource is not an exercise in Christian exclusivism. It’s an exercise in affirming the particularity of faith and producing a model others can use and follow. A one size fits all approach to faith is an immature approach to diversity. In the same way most of us have multiple protected characteristics. Seeing people through the lens of one shows how poor the imagination of much of our diversity policy and the assumptions around it still are.

The Project will be called Positive Faith (Launches late October 2017.) The resource features people from a range of Christian churches. I’ll speak about why later.

A few thanks to the people who’ve worked hard

The project is being managed and led by Catholics for AIDS Prevention and Support.  The wonderful Vicki has project managed it.  CAPS are a small charity which provides direct support and care including supporting Positive Catholics.    Our local Hertfordshire HIV Voluntary agency, HertsAid, has given significant support and effort to supporting this programme. And Public Health England have, of course, funded it.

Some reasons why we need this

First, we know from ever greater scientific evidence that for people of faith, their understanding of health challenges, their coping, even their health behaviour, is profoundly influenced by and mediated through their faith. People of faith – even those who feel excluded by it – greatly understand their health experience, even down to their efforts to live with HIV or stay free from it, in a way linked to their faith. We still lag behind in the UK with that understanding in many of our health services, despite it being a commonplace of Health Psychology for decades. We cannot do health without encountering faith in dialogue for people of faith. Ellen Idler’s 2016 book Religion as a social determinant of Public Health (Oxford University Press) is a lucid presentation of the evidence for this.

Second, health services sometimes still seem to remain squeamish, embarrassed or discomforted by the presence of faith. It’s the protected characteristic of the equality act many feel uncomfortable with. But over 40% of people in the UK still confess a religious faith of some kind. NICE guidance, NICE standards and more and more scientific evidence affirms that to personalise health care, we must recognise that we cannot treat faith as something totally private and separate from it. If a person of faith is in the clinical encounter, so is the issue of faith.

Churches struggle with HIV, Health services struggle with Faith

Faith is not going away. It is not dying. Even if you think it’s a minority pursuit, it’s important to that minority, which is still one of the largest in the country. And this resource is an attempt to redress an inequity in health – that of faith and HIV.

We must do better on this as a health system. This new resource speaks actively into that. If churches are sometimes uncomfortable about HIV, health services still feel uncomfortable about faith. This resource seeks to bridge that gap. To that extent this is a series of interventions about reducing stigma to build health equity for a population which still faces many challenges.

Why only a Christian resource so far?

Thirdly, this resource seeks to build inclusion of people with and affected by HIV in churches. To that extent, this clearly is a public health intervention. And this is why we haven’t produced a multi-faith resource. To understand HIV in the context of a particular faith, there needs to be dialogue in the language of that faith for people who have it. Yes, we need Islamic, Judaic, Hindu and more resources. And I hope people will use this approach as a template. But for a Christian black African woman to understand her HIV and her faith or for a gay male Christian to understand his faith and HIV prevention for himself or others, we and they need to relate that Christian faith specifically to health.

Is this really about prevention?

How will this prevent HIV? Well, by affirming and including people and pointing to them how much their health is something to be cherished and how much their faith acknowledges this. And we need to find a way to keep ourselves healthy and resilient to get the best from life. And health doesn’t mean a blissful state of freedom from any problem. It means adjustment to the realities of our physical, psychological and social challenges and limitations.

This resource sits firmly in the tradition of public health interventions to strengthen individuals and change communities.

More in-depth reflection

Nearer the time the Catholic Press are expected to cover this with some significant space. Articles have already been commissioned by The Tablet and The Catholic Universe .  The Catholics in Healthcare Blog will obviously carry a post. The Pastoral Review will carry a more in-depth article on the pastoral, theological and church issues around this.

The resource will be launched on 11th October 2017 by the RC Archbishop of Southwark and the Anglican Bishop of Southwark at an event in London in which people with HIV in the Video will speak. Fr Timothy Radcliffe, OP, the Master of the Dominicans, will speak alongside people with HIV.  For invitations contact Vicki Morris the Project Manager or Jim McManus the sponsor.


Skills for leading the system: Law training for leaders in #PublicHealth

I apologise in advance that some of you will find this (uncharacteristically short) post irrelevant. Some of you will find it boring.  I warrant, though, that just a few of you will find this salient and important.

On 13th October 2017, another one day masterclass for senior Public Health leaders on how to navigate the legal concepts they need to be effective in local government will run in London.  The course is free, it explicitly intends to give public health people working in local authorities the key background to the law and practice issues affecting them, and it already filling up.

Skills for managing the system

Sounds off-putting, doesn’t it?  But this course is in its fourth year and everyone I know who has been on it has found sooner or later they needed what it gave them: enough knowledge to navigate a complex issue.

People will spend a day with several senior and very experienced lawyers, getting detailed guidance, able to ask questions, and going away with a resource pack which one delegate from a previous year described as “incredibly handy: I never knew this stuff. I now know I need to know this stuff.”

The course will be delivered pro bono again this year by several amazing lawyers ; including this year Judith Barnes a senior partner at Bevan Brittan and people like Luis Andrade from Herts County Council and the Society of Local Government Lawyers.  It is a joint venture with ADPH.

There are still a few places left on this, contact to book.

It’s my fault, this idea

This course was my idea. I’m not going to apologise for inflicting it on people.  And after several requests from people to tell them why I came up with this idea, I’m sharing with you my reasons. And they’re pretty simple.

Why on earth did you come up with this?

First, local authorities run on the law.  I speak from experience of over fifteen years in local authorities. They are created by Parliament, they have many legally binding processes and a constitution, and legal issues from procuring services to making decisions are all bread and butter for senior people in local government. And these are things the public health training scheme never prepared you for.

Second, if you want to do something in local government, you need to know the legal powers and duties you have, and how to navigate them.  For example, I use a particular power in the Local Government Act 1972 to fund District Councils to do public health work which saves me a significant amount of process and cost.  Planning, Licensing,  dealing with Anti-Social Behaviour, dealing with air pollution: they all require an understanding of the legal principles.

Third, you have to know what makes a system works if you are going to use that to the benefit of the public’s health, whether by making the system work more effectively or bypassing it.

Fourth, public health leaders need to be equipped with the same knowledge as their peers to be effective in working with them.

What use has it been?

I’ve just finished a round of telephone conversations with a small sample of people who have been through the course. The common benefits people identified from being on this programme are those below:

  • Knowledge – knowing enough to know when they need expert legal help
  • Agility – being able to identify potential solutions
  • Being on a level playing field with other senior managers who know this stuff
  • Confidence that they can promote the public health work and defend the budget and team
  • Ability to recognise a potential problem and deal with it early

So, if you are going on the next masterclass, enjoy. If you haven’t, get in quick.








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.