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Using complex systems thinking to influence the way a city phe2018 gf
- 1. Using complex systems thinking to influence the way a city promotes health Greg Fell Director of Public Health, Sheffield Greg.fell@sheffield.gov.uk @felly500 https://gregfellpublichealth.wordpress.com/
- 2. Context. 5 things on my job description 1. Transform PH, from NHS facing to LG facing 2. PH is NOT the PH Grant, but totality of org 3. Stat Duty = to improve health of pop, not to provide some PH services 4. Job - influence the futures that don’t yet exist, often influencing other people’s money 5. Metric = the gap in h life expectancy …..Oh…. And “write a strategy”
- 3. There IS a PH strategy in Sheffield • I wont bore you with the detail • But its only 5 pages long. I will tell you a story about context, reflections and contextualise in complexity
- 4. Starting point - this working backward? Health ≠ the NHS …………
- 5. Or this working forward Determinants ≠ inequalities. Inequalities ≠ public health
- 6. EACH of the “determinants” is a complex system. And is not fluffy. They all interact. And have a bearing on inequality https://localdemocracyandhealth.com/2017/06/25/the-welfare-benefit-system-is-a-public-health-system/ NHS = £114bn Welfare = £160bn “social protection” = £250bn
- 7. Reflections to date • I don’t have “the answer”. No big red button. • There isn’t a single thing. Complex interplay of many different things – financial, system, intervention, political. All at once • Influence by proposition – cohorts, places, policies. Granularity of ideas – places, geography, systems • Writing a big plan wont help. • “if only we had the resources”. Mainstream vs “new” • Don’t assume “ROI” evidence will be the thing that swings it. • Evidence, data and rational argument vs belief, narrative and angriness • political, ideological or commercial influencers • Visibility is an issue! https://gregfellpublichealth.wordpress.com/2017/06/20/the-anatomy-of-a-health-city/
- 8. There’s a powerful downstream pull We often talk complexity and upstream, but act differently – empowering parents to address obesity. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60813-1/abstract https://gregfellpublichealth.wordpress.com/2018/08/24/complexity-in-public-health-part-1/ • Research, practice, policy • Strong pushback when you try to be upstream – commercial, ideological, other • “upstream” not “complex” by another name
- 9. Hierarchy approach or complex system • Analytic complexity, decision complexity, political complexity. All at once. • Hierarchy & command & control approach wont work. The end. • set broad framework, build in adaptability and regular review points • Don’t try to work out every aspect up front. System will adapt. • Set system on right trajectory. Path dependence • In control vs in charge • Set out what broadly needs to happen • Capability and capacity of system actors • System map – 1, 5, 10 year plan. Chess v draughts. • Don’t assume linearity. Take opportunities if they arise https://gregfellpublichealth.wordpress.com/2018/08/26/complexity-in-public-health-part-2-actions-to-take-responses-to-complex-problem/
- 10. Trade offs and flash-points. • Where is one set of values going to clash with another set. Discuss openly. • Economy vs well being – GVA vs wider measure. Reframe “the economy” – internalise the externality. It changes things • Air quality vs jobs - Do the maths • open dialogue about where the trade offs are??
- 11. 6 problems to be mindful of 1. Counting stuff vs having faith 2. Focus on the visible and short term vs the long term and less tangible 3. Coherent response and “a programme” vs building a culture. 4. Cant address in silos, but that will be the default. Complex adaptive systems. No single idea, no single leader 5. We quickly default to the policy or service area we are closest to. There is a great deal going on, that we as individuals might not know about 6. Austerity
- 12. There isn’t a pamphlet on this. This is a different way of doing the thing called public health
- 13. Backup
- 14. Not just the city, but upwards • Challenge assumptions at heart of govt. • OBR assumptions re NHS & social care costs. • Fair funding review • Advocacy for key policies – MUP, fast food advertising, gambling, welfare system • Structural condition for funding the things we need to fund.
- 15. The most important public health strategy you haven’t read? • Danger we will all focus on “businesses” and “the economy” • What IS “the economy” • Healthy lives are an economic investment. A bit like HS2
- 16. How far upstream do you want to go Causes of health inequitable spread of risk Causes of causes Inequitable spread of power neoliberalism Political origins of health inequities: trade and investment agreements http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31013- 3/fulltext?rss=yes Joseph Stiglitz Says Standard Economics Is Wrong. Inequality and Unearned Income Kills the Economy http://evonomics.com/joseph-stiglitz-inequality-unearned-income/
- 17. Economic power of big anchors • underplayed. • reconsider this in context of inequality. • aspiration into work and learning – what are the streams into employment and learning. • What role can anchor institutions play in this? • Anchor – role to connect aspiration to opportunity • Create a single approach as a city.
- 18. Why is it in a cities interest • Linking healthy life to service demand • Not addressing upstream risks sets up demand for our own services • LG is at bottom funding wise, now demand pressures. • A long run business case for further budget cuts? • Knowledge and values • Turn it into a performance issue for the organisation https://gregfellpublichealth.wordpress.com/2018/08/03/why-is-it-in-the-interests-of-a-city-to-improve-health-and-well-being/
Editor's Notes
- Leading edge DPH
- Upstream. “The determinants” - not all nebulous upstream policy wonkery Running an education system is not nebulous. Ditto housing, ditto planning, ditto transports. Health policy is more than health care policy They also need to be on the hook around health inequalities. The NHS is NOT off the hook Health Inequality - it’s not (only) an NHS issue. Health inequalities is not a public health issue. DH – wrong sponsor agency. Will always focus on end goal, and design solutions with health service in mind first. This isn’t to let the NHS off the hook. Far from it, but it’s well beyond the NHS. If we only ever see HI as a “health thing” and people see “health” as = “NHS”, we will only ever have a downstream response. The upstream stuff will not get the impetus….. So its not so much a case of NHS being let off hook, but those upstream of NHS being put ON the hook…….. https://twitter.com/felly500/status/1014257191933698049 My take is that the NHS does not see itself having a role in health inequality reduction it thinks that’s everybody else’s job. On ‘health’, the public see the NHS’ role but nobody else’s and local govt see a bit of everything. So at risk of being precisely wrong… Mine for the NHS at the moment is… Your own work NHS pull your weight, you need to have inequality reduction at the heart of what you do. You can make a contribution to narrowing inequalities in health quicker than anyone. We know what that looks like (mostly secondary prevention), step up and get on with it. NHS, if you’re going to do more ‘prevention’ as part of the 3.4%, make sure its inequalities focussed, and not just around specific disease pathways. Focus on preventing premature multimorbidity in poorer populations Work with others NHS, integrated care needs to be purposely inequalities focussed, it isn’t NHS, really do MECC, work with your LA partners through integrated health and wellbeing services to focus holistically around individuals range of behaviours and how that links with wider determinants, psychological wellbeing and ability to undertake sustainable change NHS, you’re an anchor institution/system, that means you have a massive impact on local wider determinants of health, understand that role and work with others to maximise it NHS, look at the connections/overlaps where you work with wider determinants, behaviours, community. What are you doing in those gaps? What does it add up to? NHS mustn’t be left off the hook. Health policy is more than Healthcare policy Across policy strategy tactical operational decisions Healthcare economic housing welfare Leisure transport policy Post public health professionals including me in my experience I'm only getting to grips with some of these There’s something about systematically unpacking the complexity that underlies “the determinants of health”. From the outside the Heath care system may look like a big homogenous blob of doctors and nurses. From the inside it is not. Similarly “the determinants of health” are a series of systems, each belie vast complexity. There’s no doubt that the “welfare system” is a determinant. And that changes to it over recent years have had profound detrimental impacts on our mental and maybe physical health, at population and individual level. Making meaningful intervention in this space requires DEEP understanding of the system to be able to carry credibility and authority and thus to be able to effectively influence. One might say the same of “housing”, of “education”, of “early years”, or of “planning”. And so on. Each of theses systems is vastly diverse and complex with many different cultures and sub cultures. Many different, difficult and odd incentives with people pulling in many different directions. As a jobbing DPH, I cant be, and am not, expert in all areas. I know a bit about some of them. Definitely, an effort is needed to shift balance of “public health” away from “health” as defined as health care services. Most know my view that “health NHS) and that “lifestlyes” might be better characterised as commercial determinants of health (As an aside there’s an interesting conundrum there. Should we ignore “smoking” because it is a downstream lifestlye issue, and result of “choices individuals make”…. It causes c12% of illness and 20% of death.) Also I know you’ve given PHE a hard time for being too physical health centric and lifestyle centric….maybe it’s good to expand the range of actors that are involved in the pursuit of “public health” – knowingly or unknowingly, even if those actors don’t call it public health, doesn’t really matter to me if the objective is shared. To be fair it’s my type that need to play into this agenda rather than vice versa Certainly in Sheffield we are clear that PH = organisational responsibility and not a “department” or a line in the budget. This is easier said than done, there’s an element of (my) “personal” responsibility and accountability. But yes, “welfare” is a definitive public health system. Public health types (defined narrowly and with a big P and a big H haven’t engaged in it as well as we might. Let’s put that right? REPLY • • markgamsu PERMALINK* June 29, 2017 20:50 Cheers Greg – and welcome to the blog! I agree with you – we have a range of social support systems and others like education that are about personal development and change – yet most of them are tremendously complicated to access for individuals and hard to understand for many professionals. When we met recently I flagged up that I have had a green flag to establish a special interest group on this topic within the Faculty of Public Health and am very keen that we extend an invitation to a number of welfare system experts to work with us – so watch this space. Yes, I have given PHE a bit of a hard time – but only because their role is so important -their position and expertise represents the biggest single chunk of Public Health resource for change in the country it therefore needs to be relevant! Mark As resident expert...... is there such a thing as a guide to the welfare system, things you need to know as a busy jobbing frontline clinician The role of the GP around social determinants Don't call them determinants - makes them seem a bit nebulous Individual level Community level Population level Primary, secondary and tertiary prevention What is it that you're trying to prevent Consistently point out the obvious, coordinate this at scale https://localdemocracyandhealth.com/2017/06/25/the-welfare-benefit-system-is-a-public-health-system/ Great blog as ever. There’s something about systematically unpacking the complexity that underlies “the determinants of health”. From the outside the Heath care system may look like a big homogenous blob of doctors and nurses. From the inside it is not. Similarly “the determinants of health” are a series of systems, each belie vast complexity. There’s no doubt that the “welfare system” is a determinant. And that changes to it over recent years have had profound detrimental impacts on our mental and maybe physical health, at population and individual level. Making meaningful intervention in this space requires DEEP understanding of the system to be able to carry credibility and authority and thus to be able to effectively influence. One might say the same of “housing”, of “education”, of “early years”, or of “planning”. And so on. Each of theses systems is vastly diverse and complex with many different cultures and sub cultures. Many different, difficult and odd incentives with people pulling in many different directions. As a jobbing DPH, I cant be, and am not, expert in all areas. I know a bit about some of them. Definitely, an effort is needed to shift balance of “public health” away from “health” as defined as health care services. Most know my view that “health NHS) and that “lifestlyes” might be better characterised as commercial determinants of health (As an aside there’s an interesting conundrum there. Should we ignore “smoking” because it is a downstream lifestlye issue, and result of “choices individuals make”…. It causes c12% of illness and 20% of death.) Also I know you’ve given PHE a hard time for being too physical health centric and lifestyle centric….maybe it’s good to expand the range of actors that are involved in the pursuit of “public health” – knowingly or unknowingly, even if those actors don’t call it public health, doesn’t really matter to me if the objective is shared. To be fair it’s my type that need to play into this agenda rather than vice versa Certainly in Sheffield we are clear that PH = organisational responsibility and not a “department” or a line in the budget. This is easier said than done, there’s an element of (my) “personal” responsibility and accountability. But yes, “welfare” is a definitive public health system. Public health types (defined narrowly and with a big P and a big H haven’t engaged in it as well as we might. Let’s put that right? Cheers Greg – and welcome to the blog! I agree with you – we have a range of social support systems and others like education that are about personal development and change – yet most of them are tremendously complicated to access for individuals and hard to understand for many professionals. When we met recently I flagged up that I have had a green flag to establish a special interest group on this topic within the Faculty of Public Health and am very keen that we extend an invitation to a number of welfare system experts to work with us – so watch this space. Yes, I have given PHE a bit of a hard time – but only because their role is so important -their position and expertise represents the biggest single chunk of Public Health resource for change in the country it therefore needs to be relevant! I suspect it is situational. Knowing when to shout, when to whisper. And to whom.
- No single big idea - . Value of the process Got to build it with conditions on the ground Representation of truth, evidence, value of evidence
- Clearly establish the direction of change wider logic models & feeds of “what works”. Interventions would introduce system learning processes rather than specifying outcomes or targets. Feedback loops. competencies, capacity, motivations of all the actors in the system initial conditions which produce a long-term momentum or ‘path dependence’. Don’t assume linearity the visibility problem – “but there’s nothing going on”. 1,5,20 year plan. Chess not draughts The national rules – can you influence, change to make your job easier?
- Lets have open dialogue about where the trade offs are?? Recognise flashpoints and trade-offs. Eg - Cars/ economy/ congestion/ AQ/ Active travel (often a false flag when you REALLY stop to think about it) Belief sets and national rules may slow progress – eg DfT and travel budget, preference for cars. Where does “growth” and “economy” clash with “well being” (I often get into reframing the word “economy” at that point) Where does efficiency clash with equity and or community focused approaches….
- Austerity harms, 7 years into a 4 year programme of austerity. It has forced change, change is welcome. But we are well beyond trimming fat – now into bone. Resist single sector and silver bullet answers: all domains need answers and solutions. Resist single sector answers. Most are unconvinced that “writing plans” will solve or make much progress No single big idea - Complex interplay of many different things – financial, system, intervention, political. All at once. Influence by proposition – cohorts, places, policies. Granularity of ideas – places, geography, systems The one thing – austerity As per chat – austerity is perhaps the one thing that might prove somewhat silverish in its bullet like status No doubt that as a result of 7 years of austerity we have stripped out hundereds of millions of spend from our authority. Same story up and down country. That spend we’ve stripped out wasn’t money for old rope – was largely prevention and early intervention services. Obviously we will have to repay the financial and human cost of that in the future. Depending on your economic lens on the world, it’s a false economy. There’s little doubt in most DPH minds that austerity is doing harm – both directly to individuals and indirectly via no longer having a range of safety net services. See the ongoing commentary on the slow down / grinding to a halt of healthy life expectancy and life expectancy – this is what’s driving demand…… It is hard for people to step outside their organisational focus and context and experience. People view the world from their perspectives and world views. This is understandable. Many specific examples cropped up in the afternoon. Illustrates how we need to overtly flag up this risk to our thinking as we take it forward. Correct the issue re fragments within a sector, and between sectors. ROI across agencies, over many years. Standard public service reform problems exist in this space, eg investment by organisation x leads to savings for organisation y These concerns are set against the impact of austerity on local government budgets and welfare reform, and what they mean for the determinants of health; and met with the response that much activity is taking place.
- Social value and how we use our institutions/assets – link to inclusive growth, procurement work – but need to think wider than this – eg can employment practices be more supportive?
- Why is it in the interests of a city to improve health and well being Summary points “Health” and “well being” are flip sides of the same coin. There is a whole philosophical debate about the definition of “health” and of “well being”, salotogenesis theory. One for another time We have an approach to this in the city where we have “health” or “well being” as a theme running through all policies. Not addressing well being or health simply sets up demand for services. Demand for NHS and social care is a response to failure to optimise this further upstream and is buying back health that we've already lost via policy choices in other spaces. Social care demand will be the bit that bankrupts any local authority. Thus considering the upstream causes of that demand is a highly legitimate goal. Upstream includes the built environment, green space, transport policy. Thus the role of the Sheffield Plan is critical "We should have a health in all policies approach", or "we should be more preventive". Both are easy to say and the right aspiration to have. How we build our environment and city - built places, social neighbourhoods, the services we provide, what the economy looks like and how it develops and includes all. All of this, and much more, matters and matters a lot for how healthy we are. We underweight the importance and relevance to "health" of changes we make in landing service and policy discussions, we underweight health (by which I don’t mean health care) and inequalities in outcomes in the trade offs we make. We still aren’t landing the rationale for why PH folk hassle others to build bike lanes, parks, not advertise junk, do progressive licencing etc. Here are some thoughts on linking "how healthy we are" it back to demand for our services. Defining "health" and why is matters to service demand Healthy Life Expectancy (HLE) is the standard proxy used for describing years in wellness or illness, or lack of it. Other metrics are available (activities of daily living, functional ability), there are some distinguishing features but they are all sides of the same coin. All have tricky methodological issues with calculation. We have broadly accepted that HLE is the measure. It can be readily linked to NHS demand. More people with more years of less than good health. That demand is inequitably spread - affluent / poor, mental illness / not etc. This leads to demand for NHS and social care (and arguably is THE point of the NHS's newfound enthusiasm for "population health".) Social care demand is related directly to how poorly people are (that’s a medical model construct) or loss of independence (often related to consequence of decline related to illness or broader social factors) It is easy to track that back to interventions to reduce or manage risk, and thus delay complications (and thus loss of functional ability, illness etc). This is easy to do re NHS services, easy to track back (or forward) to social care. These risks are due to well known risk factors. Downstream and upstream risk factors matter. Upstream always matters a lot more. Not addressing risks sets up demand for our own services. Thus it IS important to set up an environment where people can be healthy, it is an investment in preventing future demand. To use an over simplistic example, if we build a city like Amsterdam more people will walk and cycle, there will be less obesity, less downstream complications of obesity - diabetes, cancer, heart disease, joint pain. And all the NHS demand, and loss of function thus social care demand that ensues. The city will be more connected, likely mental health will improve. Some if this is near impossible to prove in modelling terms, though plenty have done this - see here (Pop benefits of Dutch levels of cycling) for an example directly linking active travel, health status and economic productivity via GDP . Having a healthier set of folk than you would otherwise is probably the biggest, and seemingly as yet untapped by those that "do" the economy, economic lever you can pull at a city level. I’ve written a little on that before – the link between “health” and economy is two way.. Im not only picking on bike lanes here, though there are a neat simple example. The same can be said in almost any area of policy. Thus it IS in the cities interests that we DO use the various levers available to us to get a healthier set of folk than would otherwise be the case. Why don’t we do better. Many obvious reasons. Austerity has led to us stripping out lots of service to maintain statutory. Even before austerity, however, this was an issue. “health (or “prevention”) isn’t my job, its done by someone else, somewhere else, leave me alone I’ve got other stuff to do”. There is something in here about business planning/budget/accountancy We didn’t want to make severe cuts to any of our preventive services. Circumstance dictated that result – we need to balance this budget NOW, we have these stat services we must deliver, something has to go somewhere, etc. We can’t fix the problem of the amount of money available – so will need to affect that decision process in other ways. This is the classic Public Service Reform problem of where returns on investment go – and how long they take to accrue. Given that we cant make the challenge go away, there IS a case to add more information to the frame so it is not just a financial calculation – or can we design a budgeting/business planning approach that exposes the dependencies across the system (so we can model “make this cut now and you will add 5x the pressure to future budgets”). We probably don’t have the data for this sort of approach, or peraps the capacity (and maybe the capability) for the modelling A “business case for cuts” process might be an interesting exercise. Makes it more complex, admittedly. The mechanism/what would need to be in place for someone (cabinet? EMT?) to be able to say “the long-term implications of change x in service y for service z is not something we can ignore – go away and think again” and possibly then look to move some money around the system in response? This might make budget setting even more terrifyingly complex than it is already. More broadly and away from narrow budget view: application of COM-B to this might be useful what is the behaviour we want from colleagues on this – need to define this clearly, something like “decision making with full view of the long term outcomes and implications”? Then from this, do they have capability, opportunity, motivation? Suspect capability and motivation might be a problem, haven’t really thought through opportunity. Knowledge is important but values too. Who are we delivering for? Eg think the evidence on active travel etc is well understood but we are continually under ambitious. Ultimately it needs to be a performance issue for Directors/HoS etc?