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 https://www.hertshealthevidence.org/ 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 http://www.open.edu/openlearn/body-mind/health/public-health

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 https://www.kingsfund.org.uk/projects/nhs-65/alternative-guide-new-nhs-england

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 https://www.kingsfund.org.uk/projects/verdict/has-government-delivered-new-era-public-health and this set of videos https://www.kingsfund.org.uk/audio-video/public-health-spending-roi . A further read is here https://www.kingsfund.org.uk/publications/improving-publics-health

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) http://www.fph.org.uk/uploads/DPH_Guidance_Final_v6.pdf
  2. The Local Government Association www.local.gov.uk publications are always extremely valuable and I suggest these two as starters https://www.local.gov.uk/lga-annual-public-health-report-four-years
  3. https://www.local.gov.uk/public-health-transformation-three-years

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. http://www.adph.org.uk/category/pblog/ and it’s worth checking our updates here http://www.adph.org.uk/

Mental Health

The Local Government Mental Health Challenge website is a very useful starting place to some of the issues http://www.mentalhealthchallenge.org.uk/  I find this guide on system wide (population or public health approaches to mental health) commissioning principles useful http://www.jcpmh.info/wp-content/uploads/jcpmh-publicmentalhealth-guide.pdf  and Finally, the Mental Health Foundation’s report is very good https://www.mentalhealth.org.uk/publications/better-mental-health-all-public-health-approach-mental-health-improvement

Health Inequalities

The Marmot Report is probably the best starting place https://www.local.gov.uk/marmot-review-report-fair-society-healthy-lives but there is also a social sciences answer to it too, which makes specific policy proposals, some of which we have adopted in Herts https://www.britac.ac.uk/sites/default/files/If%20you%20could%20do%20one%20thing%20-%20full%20report.pdf

The NHS Sustainability and Transformation Plans

I would look no further than the reports from The King’s Fund https://www.kingsfund.org.uk/topics/sustainability-transformation-plans

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.

Jim

 

 

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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 magdalena.vandersteen@adph.org.uk 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.

 

 

 

 

 

 

 

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.

Public Health Leadership: the conversation continues

Having been working on leadership styles appropriate to public health in the new English system, I thought it was about time to share the results of some of the conversations I’ve been having, since the last time I posted.

I’ve had conversations with a range of people about leadership and DsPH and domain skills and way back in 2011 there was a colloquium on leadership and local government at which I presented from an organizational psychology perspective and as a DPH in local government, about the leadership styles and roles of the DPH. You can find this here. http://www.sph.nhs.uk/what-we-do/how-we-can-help/local-government/lg-colloquium-1

My perspective

I come at this as a psychoogist, who is CIPD qualified and qualified in strategic learning and development. I have been involved in leadership development in local govt, nhs, third sector and faith settings since about 2000. I started doing leadership development for community safety managers in local government at the time, on secondment to the Home Office.

I’ve also done leadership development in third sector, faith and safeguarding contexts, including work on self-care for leaders.

Most importantly, from my perspective, I found a lot of the models then being discussed not very helpful for a number of reasons. Some models being advanced were too focused on technical competence. Others focused more on “holding the ring” , while others seemed to suggest a largely transactional style focused on statutorily defined functions.

I argued at the time that we need a larger model of different domains for public health leadership, and three years (and many workshops, seminars, learning sets and my own reflection on my leadership style) later, I still think that multiple domains of competence for leaders are where we need to go.  My own colleagues and teams may tell you I am good, bad, rubbish or (as I think myself) a mixed bag on my own leadership. Personally I think as leaders we are always “on the way” and need to reflect and learn as we go.

So I set about doing three pieces of work. The first was developing further the work I presented in 2011. The second was doing some work on what types of leadership “style” might be suited to public health leadership today. The third is working with ADPH and others to develop some specific “content” for public health leaders – like the seminars on understanding how local government law is crucial to working in local government these days. I hope to do more of this content stuff.

Developing future leaders is different from supporting existing ones

Public Health England have been working with a number of other agencies to produce a  programme for future public sector directors (which I think will be excellent), and will focus on building new leaders and directors across childrens’ service, adult social care, nhs, local government and public health together. This could be very powerful at integrating  and producing leaders working across the whole system. But while this is excellent, we still need some work to develop further and support existing public health leaders.

Why existing initiatives may not work for current senior public health leaders in local government

My own view is the leadership models from the NHS and those proposed by a number of agencies don’t work for the following reasons:

  • Existing models and programmes don’t necessarily incorporate the multiple domains of skill and competence the DPH needs to show to be effective
  • Another major area is how to influence across systems, when many DsPH have been trained to be technical not system leaders and some are better at it than others. Similarly the training scheme doesn’t always prepare trainees to come off it ready to do this at the level they need to in local government.
  • A third area is the domain specific knowledge and competencies for local government which need to be added to technical public health domains.
  • A fourth area is partnership and system wide distributed leadership skills, which some have more of than others.

Another point about my own experience is important here, because it has influenced me significantly. When I started in local government in 1990 (so I have been much more and longer a local government officer than an NHS one) as a new Principal Officer (as we were called then) I got sent to London or Manchester once a month for three years for a programme on skills for local government management and leadership. This ranged from technical skills (local government law) to the crucial skill of understanding the members and officers of the local authority [or even department within the local authority] I would find myself in, understanding the culture and knowing which styles of influencing and working work and which styles don’t. This was essentially a senior local government finishing school. It was the best programme I ever did. It’s a programme I wish someone had run for me as a new DPH and it’s a programme I know a lot of existing DsPH would find valuable.

It also helped me understand when to stop wasting my time in a role I would never fit and move on when needed. Not every public health leader or local government leader is right for every local authority. The issue of “person-organisation fit” was something we can easily conclude is more important in local government. But in reality it was important in the NHS, they just dealt with people who didn’t fit in different ways to local government.

Understanding leadership from the inside

The literature on leadership development is littered with reflections from people who have designed programmes have done so from “outside” the system they are looking at in one way or another , which means a particular view of what is needed or a particular solution is chosen without necessarily investigating it thoroughly from the inside out.

One of the common themes in conversation with DsPH is that a number of programmes for us seem to have been designed from “outside” the context DsPH are now in, so miss a number of issues. We need to understand the challenges from “the inside” to design effective development and programmes. Listening to DsPH in local government is going to be crucial to design effective programmes for them. Equally, helping people in local authorities and people in Public Health England learn about the other by immersing them in each other’s agencies is potentially very useful, and is happening in a number of areas with PHE people and local authority people shadowing each other. This kind of exchange can only be good.

But the issue of leadership style still needs to be addressed. There are many common areas where people across the system can do some similar work on leadership styles. But I can’t get away from the feedback I get that specific work around public health leaders in local government is still needed.

Some potential solutions from Occupational Psychology and Leadership research

So, onto the specific pieces of work. Again I stress this is “on the way”. The history of research on leadership had been typified by a range of paradigms, models and concepts which have changed, dialogued and developed over time. The “leaders are great men” theory, common in the early thirties, is one few people would seriously subscribe to now. But a bewildering array of models from trait theory, servant leadership, transformational, transaction and situational leadership to diversity leadership all exist, with varying challenges and problems. And all of them attract researchers and practitioners for different reasons. My own take after years of working on leadership is:

  1. Leadership is a set of influencing tools and mechanisms applied for a given purpose in a given context
  2. The ethical, interpersonal and intrapersonal aspects of leadership are as important as both the task and the situation/context
  3. Many models can be made to work, some are better than others, and the next model will be along in 5 minutes
  4. Be very suspicious of much but not all in airport bookshops, especially if it begins with “leadership secrets of Atila the Hun…” or some such stuff.
  5. Leaders exercise power, there is no getting away from it. That must be done ethically and connects public health leadership directly to the competence of ethical stewardship of self, resources and others.
  6. Leadership divorced from values is dangerous. Leadership without clearly understood and examined values is reckless.
  7. An effective style for the varied role of a DPH is emerging in the world of complex organisations, and I call it “adaptive strategic leadership”, about which a little more below.

Conceptualising Domains of public health and leadership – I have updated my 2011 work on Leadership and DsPH with thinking from conversations and discussions and learning events to reflect where I think some of the issues are, and you can find this here http://www.slideshare.net/jamesgmcmanus/leadership-and-ds-ph-update-oct-2014 If it’s useful, use it. If not, discard. Your comments and views would be very elpful.

I have presented these challenges using the occupational psychology concepts of “person-role fit”, “person-organisation-fit”, and “person-system” fit. My own view is many of us DsPH have been struggling to redefine our competencies and skills to be effective when our role, organization and system has changed and the leadership programme currently available have not always been right for us.

Adaptive Strategic Leadership: Conceptualising Leadership Styles – An immense amount of work has been done in the world of leadership research across complex and distributed (geographically or organizationally) systems. After a great deal of reading and reviewing and listening and reflecting it seems to me that leadership style which is adaptive and strategic (see the powerpoint in the link below) is a style which works for the role of senior public health leader in England today. Again, I’ve used the three categories of “person-role fit”, “person-organisation-fit”, and “person-system” fit above as a first way into this challenge.

Based on this work I’ve put forward some hypotheses about DPH leadership styles where I have, I hope, colligated the evidence correctly, but of course have not had either the time or resources to write up the conversations and learning with peers I have done on this, or do some really thorough primary research on this. But for what it’s worth I offer where I have got to so far.

The self-learning powerpoint of this is here http://www.slideshare.net/jamesgmcmanus/doing-the-mix-leadership-mcmanus-shorter

The detailed slides with bibliography on this is here http://www.slideshare.net/jamesgmcmanus/adaptive-strategic-public-health-leadership

And the video of my guest lecture on this is here http://blogs.herts.ac.uk/online-distance-learning/2014/03/17/public-health-guest-lecture/

Finally

I stress that all of this work is essentially “on the way”. I’d love to know what you think. Equally, I’d love to know where you think you have a better way forward

I feel we need a bunch of us to work together on this. My own view is getting this right will move us forward.

Public Health Leadership 2…on being useful

Helen Wilding, a colleague from Newcastle, kindly sent me an article on  preparing leaders in public health to work in a flatter and more distributed world. It’s a good read. And I think it chimes well with both my previous blog on this and the research I’ve been doing, summarised on powerpoint, for our public health leaders of the future at the University of Hertfordshire.

It prompted me to blog the learning I have had from a fantastic peer learning/mentoring set, which has now had its final meeting.  A small number of local govt officers with two private sector folk and some third sector people met every month to work through our strategy and challenges with each other. We did it quietly, and it worked. This, along with being asked by my boss to be the Sponsor from our Strategic Management Board on one of the new cohorts of our own LEAP leadership programme, have been amazing experiences.

The last two months we worked through the special feature on Influencing in the Harvard Business Review from July 2013.  Not what you’d think our usual reading but actually it explained

We each presented our challenge, our strategy and our ambitions for our services and there followed 90 minutes of critical and helpful feedback from our peers, once we had all read (before attending) and then spent 90 minutes discussing the section and especially a really good article on how experts gain influence by Annete Mikes et al (HBR,July/August 2013,pp 71 – 74.)

Members and senior officers often say to me that if all Public Health does is commission what it did in the NHS and no more then we have missed the biggest opportunity in over thirty years. I agree. The big question is, given how small public health functions are, how do we influence across big organisations and wider stakeholders and partners effectively?

We’re not the only ones facing this dilemma. Auditors, housing staff, lawyers, safeguarding, HR, equalities and facilities people all face similar challenges. So we fell on this article with interest and worked through it to see what we could glean.

Time Four Ts: the four competencies of successful expert influencers

Basically, the article looks at some financial institutions and suggests that experts (like lawyers, public health people etc) are good at gaining influence by using four competencies, all starting in T:

  • Trailblazing – finding new opportunities to use expertise
  • Toolmaking – developing and deploying tools that embody and spread expertise
  • Teamwork– using personal interaction to take in others’ expertise and convince people of the relevance of your own
  • Translation – personally helping decision makers understand complex content.”

Those most effective, unsurprisingly, were those experts able to combine these four competencies into useful products and outcomes for others in the organization.  In other words – they added value.

The opportunity for Public Health from this model

This strikes me as a key opportunity for public health, because this kind of stuff should be tailor made for us. But I so often heard colleagues in the learning set and people not in the set but in an outside public health in other areas talk about how public health is not influencing, isn’t getting purchase or indeed is seen as having lost its way or “advising not helping.”

But there is a another side needed to this model

But one thing our learning set reflected on, was on how to be effective in doing this, you really need to get yourself inside the head and mind of the organisation you find yourself in. One of the things we all had in common was that each of us had had a great and clear boss who knew what they wanted, some training or mentoring on specific things, things, knowledge and content about our sector which, in combination with leadership training, made us essentially “armed” with a clear sense of what we needed to achieve and a very clear sense of the tactics, mechanisms and tools we needed to get there. (Hence my working with others to co-produce a strategy, bringing in a four engines of public health model,  identifying the existing system leaders [my amazing partners] and getting work going with partners.)

Armed and dangerous in local government?

I was lucky to go on a series of introductions to local government constitution, finance, procurement and law over the past few years. I was also lucky to go on the Public Health Leadership Programme. And my doctoral studies group is immensely helpful in helping me work through the technical challenges of projects (what do I do about physical activity? What works?) and the tactics of getting it done.  There is a blend I am trying to get to of the science of public health and the art of getting it done.

Leadership programmes for Directors of Public Health are coming, which is great. Colleagues at the Local Government Association will also tell you about the Commissioning Academy and the LGAs own productivity and leadership opportunities. Not many DsPH on these so far, it seems. This will do one facet of helping and supporting us.

To do my small bit towards some of the other stuff (content, mechanisms, tools) I’ve been really luck to work with the good folks ADPH, LGA and LFPHWM to create the first two of  what I hope will be a small series of events to help DsPH become “armed and dangerous” – the rough guide/ boot camp introduction on local government law, one in London and one in Birmingham. These two law seminars are being offered pro bono by two senior local government partners of Bevan Brittan, a law firm which has a justly good reputation. They saw the opportunity and the need immediately when our lawyers approached them, and I have to say I have been impressed by how Bevan Brittan, Herts CC lawyers, and the indefatigable trio of ADPH, LGA and LFPHWM have seized this.

So, what did I learn about the four competencies?

I learned obviously that you need both sides of the coin – the four competencies and the “armed and dangerous” stuff.  On the four competencies I learned enough to create four objectives for my next year’s work. Some of this I am still planning.  I also learned enough so that my Monday early morning “what am I doing this week?” and my Friday evening “how did I do this week?” reflections have changed to incorporate these, and I have used them with some of my team.

Immediately, here are some of the things we have done and are doing:

  • Trailblazing – finding new opportunities to use expertise – applying public health skills to the JSNA, the health and social care integration agenda, helping spread behaviour change tools across the organization, and improving the health of children and older people – these are just some of the opportunities we are trying to deliver
  • Toolmaking – developing and deploying tools that embody and spread expertise – developing easy to use guides to finding and using evidence, running roadshows and helping people be confident in using it,  easy comparators to compare local areas on health outcomes. We need to do more. Pathways and tools for health across the lifespan (early intervention on self harm and mental health, for example) need to come
  • Teamwork– using personal interaction to take in others’ expertise and convince people of the relevance of your own – we get better results when we do this. For example, countryside walks funded by public health are being run by the countryside management service. Who better?
  • Translation – personally helping decision makers understand complex content – an easy guide to public health, explaining what it means, explaining what can be done.

This is just a snapshot. Essentially the whole public health strategy is an exercise in trying to be useful not just commission exactly what we commissioned in the NHS and no more.

And it also reminded me that being useful needs to understand the context one is working in, so that I can understand not only what is useful but how it can be useful.

Locating behaviour change in public health practice… some propostions

NICE have recently published their behaviour change guidance http://publications.nice.org.uk/behaviour-change-individual-approaches-ph49 and the British Academy have now released their report on social science interventions in Public Health (press release here http://www.britac.ac.uk/news/news.cfm/newsid/1041  ; report itself here http://www.britac.ac.uk/policy/Health_Inequalities.cfm . )

These two events have come almost simultaneously, and they both highlight the importance contribution of social sciences in health. The British Academy report deliberately focused (as we say in our introduction) on non-individual social science and behavioural science contributions whereas the NICE guidance focuses specifically on behaviour change. These two reports complement each other well and the key issue, as we say in the introduction, is for local areas to find public health strategies which hold population and individual measures, policy/regulatory and behaviour change methods, clinical services and health improvement services in balance. A balanced public health strategy is one which uses appropriate methods and tools for the different facets of the public health challenge we face, especially non-communicable disease.

I’ve read the NICE behaviour change guidance twice now, and I’m using it to bring together our various behaviour change intentions and programmes into a strategy as they recommend. This is a helpful and sane document with wise advice and a good framework for commissioners and providers.

On 28th January Public Health England, NICE and the Local Government Association will be holding Evidence into Practice , the first of a series of events seeking to support the introduction of evidence-based practice.  http://www.local.gov.uk/events/-/journal_content/56/10180/5751863/EVENT

I’m taking part in a panel discussion on the day, and I’ve also recently had colleagues from Public Health England spend a morning with me discusing and sharing how behaviour change approaches fit into a public health strategy.

I believe that there are several big challenges in getting behaviour change working effectively in public health programmes and strategies, and the NICE guidance is an enormous step forward, but we have much more still to do.

1. Having a conceptual framework of where behaviour change fits in public health as part of a strategy is a real challenge and no-one has really articulated this nationally yet in a clear and succinct way.

2. Understanding what method to use- do we target automatic processes or conscious ones, do we do population or individual level?

3. Policymakers often seize on one tool or method because it’s the current buzz topic and attracts a lot of scientific and practitioner interest. That doesn’t always make for  or effective strategy.

4. Many public health departments don’t have expert level behaviour science staff, and often the training we have had relies on models of behaviour change which are no longer used by experts in the field. The field has moved on, our training hasn’t.

4. The field itself is still developing – a bit like public health – and so experts and researchers in the field need to be better at communicating with policymakers

All of this leads me to conclude that we need some propositions about how we as public health practitioners take behaviour change forward.  I intend to share these with participants on 28th January.

Locating behaviour change in public health practice: some propositions

I share this because we ourselves are on the journey of working this out. It needs much more work, but we are already starting to use the framework they help us create.

I: Policymakers and commissioners need a clear Context within which Behaviour Change is used

  • The epidemiology of the UK is such that behavioural sciences can make a significant contribution to primary prevention of non-communicable disease, secondary prevention especially self-management and resilience and tertiary prevention (e.g. coping skills for breathlessness in heart failure.) Behaviour change needs to be seen within this context.
  • This contribution is alongside not instead of policy and population measures (like regulation of tobacco etc). Behaviour change is not the answer to our public health challenges. It is a part of the answer
  • A balanced public health strategy will have interventions at policy, environmental, social, sub-population and individual levels (eg the 6 levels of public health action in the Hertfordshire Public Health Strategy taken from Dettels et al,2009 http://slidesha.re/1e4CVzY ) Another way of looking at this is the Health Impact Pyramid https://www.idph.state.ia.us/adper/common/pdf/healthy_iowans/health_pyramid.pdf

Levels

Example of how they can   be applied –  Tobacco

Social – changing social norms   about health, e.g. acceptability of binge drinking, acceptability of taking   smoking breaks Behavioural economics, social marketing Young people
Biological – immunisation,   vaccinations, treatments Nicotine replacement therapy and cognitive tools for cravings
Environmental – encouraging green   transport, reducing pollution, changing the public realm Environmental cues, display legislationSmokefree playgrounds
Individual Behavioural – helping individuals to   stop smoking Individual and group behavioural change and support
Legislative –  the smoking ban, legislation on alcohol   sales The ban on smokingLegislation on displays
Structural – policy changes such as   workplace health, school health policies Workplace policiesTobacco control partnerships

II: Policymakers need Clarity of the aims and uses for Behaviour Change

  • Behaviour change can be used at population or individual or sub-population levels. Different theories, approaches and methods work for different settings. Policymakers should be aware of this.
  • Including behavioural science skills (e.g. health psychologists) in your service is essential to get it right . They need links with the academics to keep track of the field. We’ve recognised the need for links between public health practice and academic public health starting with our training and running all through our careers. It’s time behaviour sciences had this parity of esteem.
  • Behaviour change can target “automatic” cognitive/emotive processes (e.g. choice architecture and also eye position tracking on cigarette package warnings) or conscious deliberative ones (e.g. behavioural skills to negotiate safer sex.) You need to be clear which you are using for what, and why

III: Policymakers need Clarity of methods, settings and audiences for Behaviour Change

  • The experts in the field need to work with policymakers to create a framework or architecture within which local areas can understand and roll out behaviour change strategies and methods. A preliminary attempt at this is below

IV: A first step at a ready reckoner for behaviour change tools and methods

A   ready reckoner for behaviour change tools and methods

Population   Level

Group   Level

Individual   Levels

“Automatic”

processes

“Conscious” processes

“Automatic”

processes

“Conscious” processes

“Automatic”

processes

“Conscious” processes

Choice Architecture

Advertising e.g. change4 life

Nudge

Groupwork for behaviour

Targeted social marketing

Choice Architecture

Health Trainers

We   still have gaps and weaknesses in science and tools across all of these

(i.e. the science is still developing)

I hope this makes sense, and welcome your comments

Public Health Leadership…putting together the jigsaw

I’ve just finished a lengthy piece of work on putting together a session on strategic public health leadership, requested for public health postgraduates. Delighted to do it but the immediate thing which struck me is the literature on leadership continues to burgeon, and the literature on public health leadership itself is begining to grow very quickly.

It strikes me that trying to be a good public health leader today is about working in a Jigsaw. I feel very lucky to work where I work, with the people I have as managers, leaders, peers and reports. I am lucky every day to meet people who I learn something from.  So the first lesson is value the positive in what you have, while seeing the potential and the needs to change/adapt/correct/develop.

I’ve posted the final effort here so you can judge for yourself whether you think this is any good. http://www.slideshare.net/jamesgmcmanus/adaptive-strategic-public-health-leadership

In some ways this is a development of the work I contributed to led by Solutions for Public Health on the leadership role of the Director of Public Health.

•The colloquium report on co-production of public health for a new world http://www.sph.nhs.uk/sph-documents/local-government-colloquium-report
•My presentation to this on strengthening the leadership role of the DPH http://www.sph.nhs.uk/sph-documents/lg-colloquium-presentations/j.mcmanus-lg-colloquium-presentation

I claim no great expertise in this field other than a) having been interested in the psychology and practice of leadership for some years, b) being involved in running or supporting leadership programmes and c) trying to live up to my own leadership role as best I can.  Some folk will tell you I am a good leader. Some will tell you I am not. Most, I suspect, will tell you I have good points and points I could be better at and things they do better than I do.  Knowing and working with that, I think, is the important thing. After all, not even the saints were perfect. And God knows I’m not.

There remains for me the big issue of self-leadership.  I don’t believe I’m a great leader. I try to recognise my failings but the point of being human is we all have them. I’m on a journey. I have some great people around me but we are all human. That to me is the first thing in trying to lead and the thing I will still be trying to do well every day of my life, and often do less well than I should or perhaps could. There is no “magic fix” leadership or magic read.

Starting with me, hepling you cope with me and me with you

A long time ago (2003 to be precise) I was lucky enough to be on the Public Health Leadership Programme and lucky enough to be on the West Midlands cohort where we did a lot of work on personality, style, experiential learning, understanding ourselves etc.  I think I learned a lot from that, most especially the fact that I will always need to review and look at my leadership style and where we go.  Since then I’ve had the privilege of sponsoring leadership programmes and mentoring for them, and most lately I am sponsor for a fantastic group of people doing a local leadership programme. I learn huge amounts from them. Reflective learning is an important part of  the leadership task, and seeking feedback. I made a list of my leadership role models. Increasingly they are local people.  3/4 of the living ones nationally and internationally are women, several are medics, most not; some are contemplative enclosed religious, some LGBT, a mix of ages and ethnicities and the rest are all long dead but have left deeds and writings which inspire me daily.

Do that exercise for yourself and see what it shows you…do you have people who have radically different leadership styles?  If yes, learn from them about which style works in which situation.

Now try to work out where you can do better and what your weaknesses and learning points are. There are days when you will think people you encounter as a nightmare. The important thing is to remember there are days when they will think you are a nightmare, and they will be right.  Finding the good and strengths in everyone is a good position. Dealing with difficult behaviour is often where we each end up with each other. Such is the human task.

The point for me is that before you try to make sense of the world you are in,  you need to make sense of how you as a person are and what that says about how you are with other people in a team, partnership, management and leadership context. That will be an ongoing journey. So you need to know when to be gentle with yourself and when to expect better (just as you do with your colleagues.)  And then you need to build tools and techniques to work through it all. Adding in a little bit of generosity as well as discipline, along with trying (and undoubtedly failing in part) to model how you want things to be is important.

You’ll notice I take a very positive psychology approach (seeing strengths and opportunities for the good) which is informed by the fact I like the science behind positive psychology.  Some folk think that means I’m in denial about the downsides and difficulties. It isn’t, it means I see them but choose to see them as challenges to overcome in getting to positive outcomes not problems to derail me. (Try it, it makes for a much happier life.) How we see the world is important for our style of leadership. And one of my maxims is never to do pessimism in public. It pays off!

Pieces of a Jigsaw – the roadmap to better public health

So, I mentioned the Jigsaw. Here, so far, are the pieces I think are part of the public health leadership challenge:

  1. The epidemiology of the area
  2. The strategic challenge of what that means for health and the public purse
  3. Where the epidemiology says we need to go
  4. The aspirations and desires of members
  5. Integrating effectively into local government while managing to work well with partners and support the NHS healthcare public health job
  6. The state of the evidence base
  7. The fiscal and strategic context of where we work
  8. Putting all that together into a clear strategy
  9. Articulating it
  10. Delivering it – a jigsaw in itself
  11. Evaluating it
  12. Keeping yourself resilient, reflective and delivering
  13. Keeping others enjoying, learning and delivering
  14. Adapting and changing as the world around us changes

All of these pieces of the jigsaw can be broken down further.  Our strategy is now in place http://www.hertsdirect.org/docs/pdf/p/phstrat.pdf (so one pile of hard work is done, and the next bit of hard work begins.)

The delivery jigsaw

I mentioned this is a jigsaw in itself. Working with delivery partners and other commissioners is crucial. And getting delivery is also crucial. That’s two bits of the delivery Jigsaw. We’re busy rolling out a number of new programmes already (320 people have been referred to our new weight management programme in just six weeks since the doors opened, for example.)

A third bit is configuring the public health service itself. You’ll find that locally we’re using a “four engines” approach of evidence/analysis, technical public health expertise, project management to deliver and commissioning to get delivery. We’re also using amazing delivery partners.  Others take a different approach. You can read about our project management delivery framework here  http://www.slideshare.net/jamesgmcmanus/hertfordshire-programme-management-approach-to-public-health

A fourth part is then articulating the levels at which public health needs to be done. In Hertfordshire we’ve articulated in Chapter 3 of our strategy the components of our model – i) a clear definition of public health, ii) understanding the domains of health improvement, health protection and service delivery and quality and iii) using the six levels of public health from individual to population level.  We’ve also articulated the mechanisms of Boards and so on.  Trying to be a public health leader in this context is about trying to articulate this landscape clearly.  We have more to do on that.

A fifth part of the jigsaw is about articulating where behaviour change sits in this whole world, and what it does for us. (I intend the next blog piece to be about that.)

The jigsaw isn’t complete…I’ve left huge amounts out. some people will wish I’d talked more about evaluation and performance..there is enormous work going on behind the scenes by some colleagues doing painstaking and difficult work on getting existing services right, and it is hard work. But I think we will get there. And we will learn a lot – and hopefully have some fun along the way.

Some Leadership top reads

I provide a fairly detailed bibliography in my powerpoint, but here are my top reads on leadership. But there are a number below which if you have the time I have found very valuable. Some of these you will love, some of these you will hate. Such is the very personal nature of Leadership and writing on it.

SOME OF MY TOP TIPS

Alexander Haslam’s New Psychology of Leadership, 2012

Ayman and Chemer’s 2014 forthcoming re-issue of the 2007 classic An Integrative Theory of Leadership

Daniel Pinnow’s new 2014 Leadership: what really matters

Michael Rumsey’s the Oxford Handbook of Leadership 2012

Martin Iszaat -White and Christopher Saunders forthcoming Leadership by Oxford University Press (if you’ve liked their research, you’ll like their book)

And the forthcoming Oxford Handbook of Political Leadership by Rhodes and Hart, which has an impressive line up of authors on the nature and challenges of political leadership internationally.

SAFE AND GOOD READS

•Haslam, A et al (2010) The New Psychology of Leadership. Psychology Press
•Iszaat-White, M and Saunders, C (2014) Leadership. Oxford: Oxford University Press
•Lane, J, & Wallis, J 2009, ‘Strategic management and public leadership’, Public Management Review, 11, 1, pp. 101-120
•Lewis, Sarah (2011) Positive Psychology at Work. Chichester: Wiley-Blackwell
•Pinner, D (2011) Leadership: what really matters. New York: Springer
•Tummers, L, & Knies, E 2013, ‘Leadership and Meaningful Work in the Public Sector’, Public Administration Review, 73, 6, pp. 859-868
•GOOD FOR THE SHELF
•Linley, P et al (2013) Oxford Handbook of  Positive Psychology and Work. NY: Oxford University Press
•WORTH PRE-ORDERING
•Barling, J (2014) The Science of Leadership. New York: Oxford University Press
•De Haan (2014) The Leadership Shadow. London: Kogan Page