This document summarizes a presentation given by Professor Jim McManus on how local governments can tackle complex public health challenges through systems thinking. The presentation discusses how local authorities operate within complex systems with multiple interacting factors. It provides examples of how Hertfordshire County Council uses systems analysis to understand issues like mental health and LGBTQ youth experiences. The presentation argues that systems thinking can help conceptualize problems and identify effective policy responses. It emphasizes using tools iteratively, reflecting on practice to create change, and the importance of leadership through "symphonic thinking" to coordinate diverse actors toward improving population health.

1. Complex public health challenges and
local action:
How does local government tackle complexity?
Health Foundation Webinar, 2nd November 2017
Professor Jim McManus
Director of Public Health, Hertfordshire County Council
Health Foundation Generation Q Fellow
Jim.mcmanus@hertfordshire.gov.uk
@jimmcmanusph
1 sec

2. www.hertfordshire.gov.uk
Webinar presentation : complex public
health challenges and local action
http://www.health.org.uk/events/webinar-complex-public-health-
challenges-and-local-action-how-does-local-government-tackle

3. www.hertfordshire.gov.uk
Background to Webinar
This presentation is done for a Health Foundation Webinar on 2nd November 2017 on how local
authorities manage complexity in public health. Health Foundation webinars can be viewed here
http://www.health.org.uk/collection/webinars
In 2017 local authorities find themselves challenged by a variety of persistent and stubborn public
health problems such as obesity, air pollution and alcohol-related harm. All take place within
complex systems, with multiple factors operating over many decades in contexts that adapt and
change over time.This webinar explores why we need to think about these public health challenges
in terms of complex systems and therefore use different evidence and develop new, more effective
approaches to tackling them. We will bring together practice and research perspectives to discuss
how we use this thinking to design and evaluate population-level interventions differently to improve
health.
Speakers
•Professor Harry Rutter, Senior Clinical Research Fellow at London School of Hygiene and Tropical
Medicine
•Professor Jim McManus, Director of Public Health, Hertfordshire County Council
•Jane Landon, Strategy Advisor, The Health Foundation.

4. www.hertfordshire.gov.uk
Aims for this webinar....
• To share practical information with our audiences about
the need to develop a new model of evidence to help
policy makers and public health practitioners develop
and evaluate more effective responses to public health
challenges.
• To explore why we need to think about these challenges
in terms of complex systems, use different evidence and
develop new, more effective approaches. It will bring
together practice and research perspectives to discuss
how we use this thinking to design and evaluate
population-level interventions differently to improve
health.

5. www.hertfordshire.gov.uk
The system I face every day…
• Life is complex, it’s the models that are too
simplistic
– Complexity is part and parcel of what local
authorities do, we just haven’t always
labelled it
– By contrast I think Public Health has not
always been so at ease with complexity
• The paradigm of the evidence pyramid can’t
handle complexity…
• two examples of complexity coming……

6. www.hertfordshire.gov.uk
Key points about local government
• Since at least the mid-2000s, local government has
increasingly come to see its role as being an enabler,
– bringing together groups of people, from transport to
economic growth, regeneration, troubled families,
public health
– becoming ‘place shapers’ than just direct service
providers.
– For local govt it’s pointless to use something
inaccessible or over-complicated
– Action oriented not triumph of theory over practice
15 secs

7. www.hertfordshire.gov.uk
My organisation and system
• 1.2million residents, 37 major settlements
• Three tiers of local government
• 100+ key partners
• £817 million revenue budget 2017/18
• £223 million capital budget 2017/18
• 8000 staff
• 78 councillors
• 4 main offices, 15 touch downs (soon to be 17) (DOWN from 25)
• 46 libraries
• 29 fire stations
• 537 schools
• 17 household waste recycling centres
• Maintain 3,000 miles of roads and pavements, 100,000 street lights, and
118,000 signs.
2,200+ statutory
responsibilities

8. www.hertfordshire.gov.uk
Mechanisms and Levers in complex
systems
• A variety of different
mechanisms and
levers, from political
to officer and
technical, can be
brought to bear by
local government on
complex issues. We
need to think and
operate in this space
comfortably
• Statutory duties
• Statutory powers
• Discretionary powers
• Influence
• Assets
• partnerships
Key issue is to
be able to use a
range of them
appropriately

9. www.hertfordshire.gov.uk
So how do I work with a systems
approach? – a mental framework
Level of analysis
(Iterate between these)
Models and tools
Conceptualise the world you’re trying
to influence
Use systems tools here – causal loops,
network diagrams, systems analyses. A
range of tools and techniques
Consider the levels of influence both
biological to environmental and across
the lifecourse
(The Six levels and layers)
Consider the evidence paradigm You don’t need randomized controlled
trials for bridges!
Refine and adapt as you go on to build
your “multi-layered model” of the reality
you are working with
Systems tools and approaches

10. www.hertfordshire.gov.uk
Public Mental Health:
Complexity is a given for influences. So it should be for policy
Source: Hertfordshire Public Health Strategy 2014-17
© Copyright, Hertfordshire County Council 2014
The range of stressors
mean we need to take
a systems approach to
conceptualise them
properly.
Systems approaches
can help us
conceptualise these,
and their inter-
relationships, as well
as hypothesise about
actions
TALK THROUGH
THE EXAMPLE TO
ILLUSTRATE THE
POINT

11. www.hertfordshire.gov.uk
LGBTQ Young People
systems analysis identified actions to take
Levels
• Environment/Organisation
• Interpersonal
• Intrapersonal
Example High Level Tasks
• Policy, training, systematic
monitoring, access, quality,
Building
• social norms
• LGB literate public services,
LGB equality in
work/education/services
• Resilience, self worth, LGB
literate health care

12. www.hertfordshire.gov.uk
Tobacco
Control and
the six levels
of system
action
Remember this is a model. If
you started somewhere else,
eg modelling influences from
manufacturers, your system
analysis would be different
Source: Hertfordshire Public Health
Strategy 2014-17
© Copyright, Hertfordshire County
Council 2014

13. www.hertfordshire.gov.uk
What have I learned after 5 years trying?
• This is a different style of working, influencing
and advocating
• Systems thinking becomes a tool for leadership
in your portfolio
• It sits alongside other tools and skills
• Agility of thinking and repertoire of tools become
watchwords
• How you apply these is as crucial as being able
to choose
• As much art as science

14. www.hertfordshire.gov.uk
Getting to be comfortable with systems
approaches as a leadership task
• Reflection upon the world while engaged in
practice in order to change it

15. www.hertfordshire.gov.uk
Systems leadership as an example:
prevention in an entire population system
What we’re currently trying to do – Hearts, Minds, Action
1. Attempt to do system wide prevention eg
1. Children and young people
2. Adults with disabilities and care needs
3. Contractors
4. Employees
5. Use our own assets to meet our healthy housing ambitions for
the population – Herts Living Ltd Property Company
6. Facilitating collaboration across sectors (eg 7 tasks for
employers for mentally healthy workplaces)
2. Use systems approaches to understand, prioritise, act and adapt
3. Using the cycle in the previous slide to guide this process
4. Symphonic Thinking

16. www.hertfordshire.gov.uk
Symphonic thinking key to leadership in
complex systems
Symphonic thinking is the signature ability of
composers and conductors, whose jobs involve
corralling a diverse group of notes, instruments,
and performers producing a unified and
pleasing sound. Entrepreneurs and inventors
have long relied on this ability. But today,
Symphony is becoming an essential aptitude
for a much wider swath of the population.”
Daniel H. Pink (2005)
A Whole New Mind: Moving from the Information Age to the Conceptual
Age

17. www.hertfordshire.gov.uk
use tools but stay true to reality
“Systems awareness and systems design are important for health
professionals, but they are not enough. They are enabling
mechanisms only.
It is the ethical dimensions of individuals that are essential to a
system’s success. Ultimately, the secret of quality is love. You
have to love your patient, you have to love your profession, you
have to love your God. If you have love, you can then work
backward to monitor and improve the system.”
Avedis Donabedian
(pioneer of healthcare quality approaches)

18. www.hertfordshire.gov.uk
Some golden rules
Take the plunge, don’t just talk
• If you’ve never
worked in local
government:
– don’t take a deficit
approach – “the
expert”
– spend some time in
the system before
you pontificate
• If you’re in a local
system:
– Use systems in the
cycle of reflection and
action
– start somewhere,
– get others on board
– Work across the system
– Walk before you can run

19. Jim.mcmanus@hertfordshire.gov.uk
@jimmcmanusph
Thank you