This document summarizes a presentation on local leadership to reduce health inequalities. It discusses using multiple lenses to understand complex issues like COVID-19 and inequalities, including layers of determinants, systems thinking, and a syndemics approach. It advocates exiting the pandemic phase by managing COVID-19 as part of ongoing health protection with a focus on recovering services to address inequalities impacts. Building back fairer requires reducing inequalities across the system by embracing evidence, population health management, and prevention from school to employment through multiple actors working together.

1. Local Leadership to reduce Health
Inequalities: Where Next?
Systems, Syndemics, Determinants
Prof Jim McManus, FBPsS, CPsychol, CSci, FFPH,
FCIPD,FRSB
LGA Conference 23rd March 2021
Vice President, Association of Directors of Public Health
Director of Public Health, Hertfordshire County Council

2. 3/23/2021
LEADERSHIP SCORECARD FOR INEQUALITIES
I have based these on the Four Domains of Leadership developed for the Health
Foundation by Ashridge Hult Business School and the Health Foundation
• Self care plan
• Leadership and influencing style
• Finding time to do the important
and the thinking as well as the
urgent
PERSONAL
• Keeping your skills up to date.
Art as well as science. Having a
ready reckoner of who leads on
stuff
• Legal, Media, Influencing and
Quality Skills every bit as
important as Science
TECHNICAL : SCIENCE AND ART
• Understand local government
and the NHS, and how it works.
• The soft as well as hard
systems
• power structures of getting
things done
CONTEXTUAL : THE
SYSTEM YOU’RE IN
• Key Relationships: Some
shift,some are enduring. Your
exec member, CEO and peers
and NHS CEO need to be key.
Others may shift.
• Build a “board of allies”
INTERPERSONAL

3. “Enduring
Transmission”
Reflecting
scientifically and
ethically
• It helps us respond to
some areas because it
encapsulates a new
phenomenon
• It’s a useful short-
hand term for what is
a national
phemonenon
• It masks response by
oversimplifying
multiple infection
dynamics and the
impact of inequalities
on them
• The very shorthand
obscures the
complexity of the
problem preventing
• Inequalities are at the
root of multiple
propagated epidemics
all with different
drivers. Good
epidemiology should
understand and
complexify this, not
buy into recently
made up buzzwords
• This is linear thinking
and we need a
different style of
thinking
www.adph.org.uk

4. Questions
about
enduring
transmission
…
www.adph.org.uk
• Is enduring transmission really enduring...or is it
multiple connected and unconnected phenomena
better informed by systems and chaos theory
than the linear thinking enduring transmission
suggests.
• Linear thinking in a disease pandemic risks
missing the point about complex drivers of
infection.
• the problem with the phrase enduring
transmission is it seeks to simplify what ought to
be complexified in order to understand and direct
action on a diverse range of drivers which differ
from area to area
• And when models simplify too much, they break
down and fail to serve

5. “Living with
COVID”
www.adph.org.uk
• ADPH Policy Paper
• Calls for a focus on inequalities –
Build back fairer
• Inequalities have worsened
• “Complexifying” the impacts of
Covid
• A move away from linear thinking
on inequalities to multiple causes
– complexify
• Let’s look at self-isolation as an
example…the Hertfordshire Day of
Action, visits to 1,000 households

6. www.adph.org.uk

7. We have tried
and tested tools
for
Complexifying
Inequalities to
understand
multiple factors
• What does a local
system do then….?
• Three Lenses
1. Layers of determinants –
(Dettells 1990) from
biological to social
2. Systems Lens
3. Syndemic Lens
www.adph.org.uk
I wont focus on the Determinants,
the Marmot Refresh speaks eloquently
to these

8. Why whole Systems?
www.adph.org.uk
https://www.youtube.com/watch?v=SLu9AOpfsjs
https://www.gov.uk/government/publications/health-matters-whole-systems-
approach-to-obesity/health-matters-whole-systems-approach-to-obesity
Because - multiple impacts and determinants

10. Why Syndemic? Coronavirus:
Pandemic or Syndemic?
Inequalities: Pandemic or
Syndemic? • 1st Wave: Immediate
mortality and morbidity
of COVID-19.
• 1st Wave Tail: Post-ICU
and admission recovery
for many patients.
• 2nd Wave: Impact of
resource restrictions on
non-COVID conditions –
all the usual urgent
things that people need
immediate treatment for
– acute.
• 3rd Wave: The impact of
interrupted care of
chronic conditions
(people stayed home).
• 4th Wave: Psychic
trauma, mental illness,
PTSD, economic injury,
burnout, and more.

11. Example:
Complexifying
COVID-19 and
BAME
Populations
Social, cultural
and structural
determinants
11
Source: Public Health England
Syndemics and systems lenses inform the complexity of the issue

12. COVID-19 in Black, Asian and Minority
Ethnic populations: An evidence review and
recommendations from SAHF (2020).
Available at:
https://www.sahf.org.uk/covid19

13. Exit The
Pandemic:
Exit the
Pandemic
Phase and
Manage Covid
as part of an
ongoing health
protection
approach
Exit Plan for running Covid Exit alongside
non covid work for 2021-22
Surge
Ready
Plan for major covid surge in
Autumn/Winter 2021-22
Ongoing Plan for a Health Protection Strategy
where covid is one factor among
others
The NHS is only one part of the
system, not the system

14. Recover:
re-start
services and
portfolios
with an
emphasis on
addressing
impacts of
Covid
Recover
Recover core services portfolio
with redesign to address
inequalities
Prevent
Embed and enhance the
prevention strategy
Intelligence
Led Use analytics and intelligence to
identify impacts of covid and
identify priorities for equitable
recovery
Insight
Use behavioural science expertise
to improve reach and outcomes of
public services in recovery

15. Build Back
Fairer:
Reduce
Inequalities
across the
System
Determinants
• Ensure the system adopts Marmot insights
and principles across the lifecourse
including supporting healthy employment
and pathways into employment
Evidence & Intelligence
• Embed evidence and intelligence-led
inequalities response across the system
Population
• Embed population health management
ethos and practice across health and social
care all ages
Resilience
• Embed a Population Mental Health and
Resilience Aproach

16. crucial to a systems approach going
forward…
Prevention: School to Employment
Determinants, Systems, Syndemics
Quality of Place
Long Term and Medium Term Plans
Leadership: Multiple Actors
Quality of Services

18. Thank You!
Jim.mcmanus@hertfordshire.gov.uk
www.adph.org.uk