A bit of thinking on saving the country £200m…and much more…

The opinions which follow are entirely personal and do not claim to reflect those of or have endorsement by any organisation.

Folk will doubtless have read of the proposals by the Chancellor to cut £200m from the local authority public health budgets in year. We still await detail of what is proposed.

David Buck, from the King’s Fund, gives an excellent breakdown in today’s LGC (Local Government Chronicle) of why this is much more serious than initially suggested. David says that

“many unanswered questions remain, including how this relates to the transfer of children’s services from the NHS to local government planned for October. This will be worth more than £800m each year.”

David recounts that the proposal comes on top of a standstill in public health funding. Secondly, he says it seems to contradict the commitment to Prevention echoed in the NHS Five Year Forward View, and then, thirdly, reminds us that many of the services commissioned by Public Health are commissioned from the NHS. Despite the recent commitment to protect the funding of the NHS. This will impact on the NHS, and directly.  But David’s most telling point is to warn of wider consequences:

“Locally, it could easily create perverse incentives that lead away from integration. Why would clinical commissioning groups enter into pooled budgeting arrangements with local authorities, when they know their funding is safe and sacrosanct but local authorities’ money is not?”

David’s piece is here, and is well worth a read. Equally, Keith Cooper’s editorial comment in the same issue is extremely good at highlighting how this proposal will have a wider impact than just local government.

Apart from being really quite incisive sets of comments, it’s heartening how the local government press has taken enthusiastically to the potential which public health has as part of the local government family.

We are, I think, just beginning to articulate the possibilities that prevention could deliver for better lives, better health and a more sustainable public purse. It’s entirely right that the Government of the day usually has expected and should expect its public officials to deliver the “Four Es” – Economy, Effectivness, Efficiency and Equity – from public spending, especially in an era of austerity. I just think that there are much more effective and far-reaching ways of doing it than applying a poorly thought through £200m clawback.

This was highlighted yesterday and this morning with the launch of the ‘Smoking Still Kills’ strategy where the argument for preventative services is expounded; and the success to date of reducing costly and painful death and disease from tobacco is evident. Giving preventive activity time to embed really can yield differences. Locally our new approach to drug recovery is reducing the spend on residential rehabilitation and the cost to social care. There is money to be saved here, but we need to do some lateral thinking. Prevention can be made to work, but only if we see it as a system, and work as a system.

There is no way the current £200 million proposal can happen without impacting on the NHS

At an estimated 7.4% of in year public health spend, it is highly unlikely that Local Authorities will be able to achieve efficiencies across all areas of current public health spend without affecting the statutory Public Health services (e.g. sexual health, health checks ) or other NHS services which constitute a considerable proportion of the public health grant and service investment (e.g school nurses, health visitors). David Buck points out that not cutting NHS servics is a Government Manifesto commitment.

Page 38 of the Government’s Manifesto reads

“We will support you and your family to stay healthy. We are helping people to stay healthy by ending the open display of tobacco in shops, introducing plain–packaged cigarettes and funding local authority public health budgets. We will take action to reduce childhood obesity and continue to promote clear food information. We will support people struggling with addictions and undertake a review into how best to support those suffering from long-term yet treatable conditions, such as drug or alcohol addiction, or obesity, back in to work.”

As a public health professional this is inspiring. In fact, we have two social enterprises in Hertfordshire who spend all of their time getting people into work after battling drug and alcohol dependency. And they do a good job. I was hoping to expand this ethos more widely to mental health and other long term conditions but without being able to use public health money for investment, it’s unlikely the money will come from anywhere else. The current proposal  to cut £200m is not the way to help the local health economy’s existing plan for delivering those commitments, or prevention savings more widely.

Alternative Efficiency Proposals in the short term

Some colleagues and friends have been in discussion with me. And I have shamelessly purloined some of their ideas here. (You know who you are, and thank you.) If £200m really has to be saved from NHS spend this year, (and remember much public health spend is actually spend on the NHS) then I think  a more constructive approach would be to:

  1.   Give Hospital Trusts a £200m target to reduce avoidable costs from procurement and agency staff commissioning. The ‘Carter Report’ widely trailed in the news today suggests that Hospitals may not be gaining the £400m in procurement and agency savings alone they could reap in these areas[i].
  2. Give NHS Trusts a £200m target to reduce ‘interventions of limited clinical value’ in NHS provision. The Academy of Royal Collages Report (November 2014) suggests that 20% of all health care activity is effectively over-treatment as it  ‘brings no benefit to the patient’[ii] .This could be done without harming health outcomes.
  3. Introduce a Sugar Duty at 20 pence per litre in England[iii]. The impact nationally over twenty years would be to:
  •  reduce the cases of diabetes by just under 50,000
  • prevent almost 9000 cases of cancer
  • reduce strokes and cases of coronary heart disease by over 33,000
  • save the NHS at least £15million a year in healthcare costs for treating those diseases.
  • improve the quality of life for tens of thousands of residents.

4. Introduce the levy on the tobacco industry called for in Smoking still kills. This could pay for the cost to local government of social care, cleaning, litter, smoking cessation, tobacco control and other measures; and the cost to the NHS of treating diseases attributable to smoking like COPD, cancer and even Diabetes as identified by the recent report of the US Surgeon General.

All of the first 3 measures above are evidenced based (references in footnote below), would reduce costs, would bring clinical benefit to patients, would  improve health outcomes for citizens and would improve NHS productivity without reducing its capacity to prevent future demand. The fourth measure is argued for in Smoking still kills.

Additional Efficiency Proposals in the medium term

Obviously we would and could make further savings by doing things differently. Preventing diseases from escalating or worsening and treating as quickly and cheaply as possible continue to be options which we can explore further. Here are just five of my list of candidates for saving money while improving health:

  1.  Make greater use of pharmacy for minor ailments and long term conditions
  2. Drive down the cost of consultations and polypharmacy in multimorbidity by delivering models of care which address multimorbidity per se, rather than accumulating niche guidelines, treatments and consultations for multiple individual conditions. And please don’t say we’re doing that. The last 29 conversations I had on this with clinicians had one consensus point: we can do a lot better.
  3. Invest in self management – there are promising models here.
  4. Identify early high risk of escalating disease and disability and keep people at optimal levels of functioning through good pathways and practice.
  5. Learn from the five best countries in the world about keeping people with long term conditions economically active (eg in the workforce).

There are, with some thought, good implementation science and hard work, many places from which we could save sustainable sums that will be multiples of £200 million. And we could improve health into the bargain.  It wont be overnight.  The way to do it is focus the public health, local government and NHS workforce on prevention and quality, not chasing short-term cuts. You don’t even need to invest here;  just don’t cut to transform and save.








[i] Academy of Royal Collages (2014) Protecting resources, Promoting value: A doctors guide to cutting waste in clinical care http://www.aomrc.org.uk/publications/reports-a-guidance?view=docman

[ii] http://www.bbc.co.uk/news/health-33071066

[iii] The Children’s Food Campaign has  published a tool that allows people to view the impact a sugary drinks duty could have in their local area. The figures, available on www.childrenshealthfund.org.uk  show that the introduction of a duty on sugary drinks could reduce rates of diet-related diseases by tens of thousands, as well as save the NHS and public health budgets in England £300 million over twenty years.




Leadership…it’s not all transformational in public health

I don’t know about anyone else but when I was training in Public Health, things like leadership education were largely missing. I was lucky to get onto the national Public Health Leadership programme over a decade ago now, and even luckier to have other training.

And yet leadership is an absolutely central function in public health, and leadership across systems especially. http://www.slideshare.net/jamesgmcmanus/leadership-and-ds-ph-update-oct-2014

You’ll be aware from a pile of postings, articles, slideshares and other stuff that I have an interest in (obsession with?) leadership in public health.  This is at least partly due to reflections on my own failures and a desire to try and get it right. And it’s partly due to my training as a psychologist. In the last few months I have reflected again on my own leadership roles but also have done a number of sessions for new public health leaders.

One thing I have noticed is that Transformational Leadership models seem to be the flavour of the month at present. I have found transformational leadership models, especially when adapted to the public sector (e.g. the work of Beverley Alimo-Metcalfe on local government) very helpful. Try these links for more reading on this:

The last link above on Post Francis enquiry approaches is especially interesting.

But there are some challenges with Transformational Leadership models, before we go running down the road to apply them in preference to anything else:

  • Some commentators feel transformational leadership is better in an organisation. When you work across a whole system, as public health leaders need to try to do, there are additional behaviours, styles and tactics you need, and you need to flex your style much more as a system leader across different organizational cultures than just transformational models would suggest
  • Transformational leadership training is not always good at explicitly integrating the scientific background of public health senior roles with the leadership tool portfolio they need
  • There is a very thin line between transformational leadership and dictatorship or bullying. Engaging people in your system and organisation is hugely important with transformational change and leadership and rightly many researchers are now emphasising this.  Beverley Alimo-Metcalfe, who created among other things the Local Government Transformational Leadership questionnaire, has spent a great deal of time on the importance of this.

Dennis Tourish’s new book The Dark Side of Transformational Leadership (Routledge, 2014, £24.99) is a salutary read on the strengths and weaknesses of Transformational Leadership as a model and theory.  He presents a significant amount of research on transformational leadership and case studies. The book has a good style, discussion questions and reflection questions and if you’re looking for a CPD text then do yourself a favour and give it a go.  Even if you only read the last chapter on new styles of leadership and better ways of thinking about leadership.

But he makes a range of important points that Public Health leaders who are attracted to transformational styles:

  1. Tourish spends some time in his book looking at the (usually catastrophic) consequences of leaders with vision whose decisions have not been challenged or helped to mature by being reflexive or open to others. There is always the potential that leaders in trying to transform do as much harm as good
  2. Unregulated power in a leader (I’m sure many of us have been there, on whichever end) is not a good thing and a key part of leadership in a system is about being held to account as much as holding to account. Leadership seen as service, as enabling a system is better at that
  3. Transformational leadership models in people who think they know better than anyone else can become a justification for arrogance. Public Health has not always been a stranger to that arrogance about its role, importance and abilities.
  4. Transformational leadership which is all about the leader and not about the team or organization or structure can have, like any leadership style, profoundly negative consequences on others.

Transformational leadership has its place. But if you are a public health leader in a system which doesnt want you, or is dysfunctional, or where others think they know your public health job better than you, then I am unsure that transformational leadership is the solution. An adaptive style which enables you to assess situations and use a menu of styles, tools, tactics and mechanisms is more likely to be helpful.  And indeed much recent research on leadership seems to be showing that across mutliple context systems that works. http://www.slideshare.net/jamesgmcmanus/adaptive-strategic-public-health-leadership

Trying to apply this is an interesting process, and I sat down one day with a group of colleagues when we were sharing challenges and perspectives. I have some rules of thumb on leadership which seem to be working at present:

  1. There is no Perfect style or perfect leader:
    • I will never be a perfect leader and there will always be fallout from what I do. But thats not an excuse not to do better. Doing better is the whole point
    • There is no single model of leadership which is right.
      1. The best “model” (or rather frameworkk which enables us to take different bits of different models) I can find at present is that of distributed, adapted leadership which is about leading systems. It takes in a range of elements including the transformational. You can find my presentations on this here   
      2. Leadership is a journey towards being authentically you and truly effective. That journey never ends and we can all always do better
  2. As with all public health, science and art must be held in dynamic tension to be effective and authentic
    • The science of leadership, good solid psychological science, needs to be taken seriously. But the more science I read on leadership, the more I realise it’s just as much art as science.
  3. Sources of reading and learning
    • Do yourself a favour and check out reviews in decent journals like  Harvard Business Review, The Psychologist or Management Today rather than buying blind in a book shop
    • Rarely trust anything you buy in an airport book shop
    • Do Read Harvard Business Review (even if you do find it in an airport bookshop)
  4. Models can be deceptive
    • If a model or course sounds too good to be true (you will become an amazing leader in one day) it usually is.
    • Be sceptical of people who espouse a model of leadership but have never led in your context. (If you haven’t spent a day in local government, how do you truly understand the context? .)
    • Models will change and my learning and style should change as knowledge develops
    • Over-reliance on one model is usually unhelpful because it limits your grow
  5. Think of Frameworks not models
    • A framework tells you what sets of thing you may need to be doing rather than prescribing “this is how you do it”. These rules of thumb are my framework
    • Ethics, Values, Vision and Context are as much a part of any good framework as tools and tactics and inventories
  6. Leadership cannot be context independent and be effective
    • Leaders are set into not apart from the contexts they serve (so the “independence of the DPH” needs to be handled carefully here).
    • Beware the “high” doctrine of leaders as great individuals. The context and the people make the leader as much as the leader.
  7. Leadership is a service to the common good or it is nothing
    • Leadership is a portfolio of influencing skills and tactics to get to the common good (ok this is my bias, but I bet you have one too)
    • That desired good will always be changing, like everything in life
  8. As the recent Kings Fund report suggests, as a leader across systems you need to be comfortable with chaos. Please note that my and your leadership style creates at least some of that chaos anyway!
  9. Dont expect people to be gentle and trusting of your leadership style if you cant spend some time being gentle and trusting of you and them
  10. Four golden functions: Nurturing, Guiding, Healing and Reconciling and Discipline (I dont mean sticks I mean holding a line and standard to keep people to) are important in leadership, and you need to be a receiver as much as a giver of these
  11. Leadership always has a dark side or down side
    • It may be just the fallout from your style. It may be just the dysfunction of being human and imperfect. But leadership ALWAYS has a down side, at least for some of those your leadership touches. If we don’t deal with this openly and work out what to do along the journey then our leadership is unethical.

Anyway, these are the things that help me. It may be different for you. Let’s help each other on our journey.

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.


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.


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.


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.


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)!

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?