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Webinar: Complex public health challenges and local action

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This webinar explores how to effectively tackle complex public health challenges by shifting from traditional, linear approaches to embracing complex systems thinking, emphasizing the need for multi-level, long-term interventions and a rebalancing of evidence generation towards upstream, population-level actions.

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hello and welcome to this Health

Foundation webinar on complex public

health challenges and local action how

does local government to tackle

complexity I'm delighted to be here

today and it's great that so many of you

who've been able to join us my name is

Jane Landon and I'm a senior policy

fellow at the Health Foundation and I'll

be chairing the session today I'd like

now to introduce our two speakers on

this webinar on my right dr. Harry

Rutter who is clinical research research

fellow at the London School of Hygiene

and Tropical Medicine hi Harry

hi and on my left professor Jim McManus

who is the director of public health at

Hofstra County Council warm welcome Jim

thank you hello this is our first

webinar on a topic which is part of our

healthy lives work here at the Health

Foundation our healthy life strategy

aims to improve health looking beyond

the health care system by supporting

cross-sectoral action on the social

determinants of health one of the major

challenges of for Public Health is how

do we generate evidence that is useful

to decision-makers and that reflects the

multi-factor from nature of the health

issues that we face today issues such as

obesity such as poor mental health and

such as health inequalities also how do

we understand the factors which drive

these different problems as part of the

healthy life strategy we are pleased to

be working with Harry on a program of

work which aims to help overcome some of

the research challenges and to support

the use of different methodologies that

we need for population level as well as

individual level interventions we'll

hear a bit more from Harry about that in

a moment so please do send us your

questions during the presentations you

can do that by typing them into the box

on the left hand side of your screen

we'll be monitoring those questions over

the course of the presentations as they

come in and we'll start the question and

answer session once we have heard from

both of our speakers so first we're

going to hear from Harry who is going to explain

explain

now we can think about public health

challenges in terms of complex systems

to develop new approaches to both the

design and the evaluation of population

level interventions interventions that

can improve public health

thanks very much Jane so my talk today

is in just 20 minutes going to try and

start to explore some of the problems

that we face in public health that

traditional approaches have hit a bit of

a stumbling block at dealing with and

start to explore some of the ways in

which a complex systems thinking

approach might be able to help us get

over some of those challenges and then

lead into practical responses to them

that Jim is going to talk about some

more we hear a lot about evidence when

we're talking about health and rightly

so but sometimes the evidence that we

have is less helpful than it might be

and one of the metaphors I've used for

this is to come up with this idea of

something that I've called a dangerous

olive of evidence so if all of you

watching this now were to write down on

a piece of paper your top three things

that you believe would make a difference

to reducing obesity things for which we

we may not have firm evidence we may not

have a solid trial or a study anything

published in a journal but but good

ideas things that make sense

that's the stuff that sits in the flesh

of this olive the olive is stuffed with

a pepper and the pepper contains the

subset of those interventions that

you've all written down for which we do

in fact have some pretty robust evidence

that they work that pepper is then

stuffed with a very very small piece of

garlic which is the subset of those

interventions for which we have evidence

of effectiveness for which we also have

evidence of cost-effectiveness but as

I've said this is a dangerous olive and

there are concerns I think about the

kinds of things that sit within the

pepper and the guard

the kinds of interventions for which we

have evidence of effectiveness and I'd

like to try and explain why one way of

thinking about obesity is that we need a

huge range of actions at all levels of

society throughout the life course at

multiple different levels of the system

from individual level treatments such as

bariatric surgery all the way up to

reform of the Common Agricultural Policy

oh it's it's like building a wall of

sandbags against a flood but all too

often in our research what we do is we

take one sandbag out from that wall and

we might even put it in a randomized

control trial and we assess it to see if

it stops the whole flood does this

intervention on its own have an effect

on the distal outcome of obesity in many

cases we find that it doesn't but we're

judging those interventions on the wrong

criteria you wouldn't expect anyone

sandbag to stop a flood we should test a

sandbag in terms of its effectiveness at

being a sandbag not as an entire wall so

if we look at this diagram which is

adapted from one that Boyd Swinburne

used in a 2011 Lancet paper on obesity

there's a range of interventions that we

can put into place on the right hand

side we've got those individual level

interventions such as drugs or surgery

and on the left hand side we've got very

upstream policy interventions

agricultural policy taxes on sugar fat

and so on at its most extreme perhaps a

really significant tax on carbon

emissions which would affect the ways in

which we move around the kinds of foods

that get produced and so on and in the

middle we have in general the kind of

things that relate to our local

environment the numbers of fast-food

outlets on our high streets the

provision of cycle lanes or high quality

infrastructure for walking in our towns

and cities so very very broadly in this

diagram what we've got is on the left

hand side the kinds of interventions and

actions that can be taken by national

government around the middle we have the kind

kind

of interventions and actions that can be

taken by local or regional government

and on the right hand side we have

actions for the Health Service and also

for individuals and there's a there's a

wedge across the bottom there that says

population effect and political

difficulty and what we find is that the

individual level interventions can be

extremely effective in any one

individual but a population effect they

tend not to be practical at shifting the

population bariatric surgery surgery for

obesity is a very very effective

intervention in the right individuals

but we've got around one and a half

million people with a body mass index

over 40 in this country very very rough

measure of need I'm not for a moment

saying that all those people should have

surgery but as a very rough indication

we've got about 1 and a half million

people who might benefit but we do

something like 6 or 7 thousand of those

operations a year great intervention in

the right individual but it's not a

population level response on the

left-hand side of the diagram we've got

big picture population level actions

agricultural policy the kinds of things

that determine the amount of sugar and

fat flowing into our food system actions

to shift that are politically extremely

difficult to do but they could have big

picture impacts on on the distribution

of body weight across society and then

I've added three more little wedges

across the bottom all skewed over to the

right evidence base is skewed towards

the individual level public political

and media discourse is also skewed

towards the individual and as a result

political mandate is skewed towards the

individual so this is why the olive that

I showed you earlier is dangerous

because the kinds of things that sit

within the pepper and the garlic are the

kinds of things that sit on the right

hand side of this diagram it's not to

say that they're not helpful they are

they're an important part of the picture

but if that's all we do and we ignore

the more upstream things over to the

left hand side we're missing some of the

potentially most effective and most

powerful interventions there's another

aspect to this which comes from

an academic who was at my institution

the London School of Hygiene called

Geoffrey rose and Rose talked about the

difference between the population level

interventions and the targeted

interventions in high-risk populations

and one of the consequences of using

words like obesity is that we tend to

think about people at the the far end of

the population distribution people who

are perhaps candidates possibly for

surgery but what Rose pointed out is

that many of the interventions that we

could be doing to tackle population

level problems don't just involve

targeting specific individuals with with

highly with with big effect

interventions such as surgery they may

be about making very very small changes

change is so small that you couldn't

actually detect their impact impact in

any one individual but if you aggregate

them up across the entire population you

shift the distribution across that

population over to the left so we could

reduce everyone's weight by a small

amount you might not even be able to

pick that up at individual level but

across the population you would have

improvements in health across large

numbers of people so what's this got to

do with complexity and I think before

that question can be answered it's

important to grasp what we mean by

complexity because often I think the

idea of things that are very complicated

is confused with things that are complex

now there are lots and lots of different

ways of defining these words but one of

the ways that I find really helpful is

to use this analogy of a space rocket a

Saturn 5 rocket this is an incredibly

complicated piece of equipment

incredibly detailed thousands and

thousands of parts to it it would take a

very long time to build one but if you

know what you're doing you can put three

people into that little cone at the top

send it to the moon and whatever it is

five or six days later you know exactly exactly

exactly

where to pick those people up from in the

the

so it's a it's a hugely complicated

thing but it is predictable it is

controllable you press a button to

launch it and five or six days later you

know - within a minute or two and within

a few hundred meters where it's going to

end up geopolitical relationships in the

Middle East however or a rather

different category of problem and this

is what a complex problem looks like if

you intervene in any one part of this

what you find is that there are

unpredictable effects there are linkages

across this entire system this is not a

system or problem that one can solve

because a complex problem in general

isn't something that one can solve a

complex problem is something that one

can intervene in to create a

reconfiguration and lead to changes and

and a different potentially a different

set of outcomes but all too often we

conceptualize problems that look like

this as if they look like the space

rocket we even in Health Services talked

about the delivery chain as if there was

a link going to a link going to a link

going to a link when in fact we have a

whole load of interacting elements that

influence one another and things change

as things move so at the heart of

grappling with complexity is

understanding that we don't necessarily

have these kind of straight direct

linear relations between cause and

effect that much of our scientific

thinking has taught us to think about

and I've been involved in some work in

in a city recently where we've looked at

using this approach for thinking about

physical activity we've mapped out the

physical activity system and here is a

first stab at it we went for a moment

pretending that this was a definitive

definition of all the things that sit

within physical activity in a local

authority but it was a tool a way of

encapsulating some of the important

things that can be done at local

authority or at local authority level

to promote increased activity across the

population and very broadly on the

right-hand side of this diagram we've

got individual level actions providing

people with information social marketing

schemes and so on on the left-hand side

we've got more structural things cycle

lanes and so on and so forth and in the

middle we've got the kinds of things

that get measured levels of walking in

cycling and so on and so forth we've

worked with people in this local

authority and we said we're draw on this

map the kinds of things that you think

would be really helpful to do to

increase the level of walking and

cycling and physical activity in general

and and they highlighted a whole load of

activities in that structural area on

the left hand side we then got them to

map out the kinds of things that they

were currently focusing on and that was

the kinds of things that were on the

right hand side so merely by mapping out

the system and working with a group of

stakeholders to examine what bits of the

system were being acted on and what bits

were not being acted on it was possible

to identify potential areas for changing

activity for bringing near activity in

and so forth and we used it much more

than this we looked at data that could

be measured for example the kinds of

things that were already being collected

and other things that one might collect

over time to identify changes within

this system and time I think is a really

important dimension dimension that we've

often lost sight of in public health

when we're thinking to come back to

childhood obesity when we're thinking

about how we act to tackle childhood

obesity many of the things that we focus

on initially deal with understandably

and appropriately the problems of health

the health problems that arise during

childhood of course

when one wants to make sure that

children who have a weight problem are

not subject to stigma or bullying or or

physical health problems

and if we go back to the ollie of what

we find is that there are some areas in

which we do have some evidence that the

things that sit within the pepper and

the garlic that relates to this domain

the next thing we look at is the idea

that obesity in childhood tracks into

adulthood if you if you're overweight as

a child and as an adolescent it's more

likely that you will be overweight as

you go into adult life so of course

reducing the weight the weight status of

children during childhood is a helpful

thing to do it reduces the likelihood of

long-term that long-term gain but what

we all too rarely look at is the kinds

of interventions that might be

introduced in childhood that could

affect not just what happens to that

child during childhood or their weight

status at the end of childhood but

actions that might affect their behavior

across the life course one way of

thinking about this is to use the

example of a walking school bus and my

kids used to do a walking school bus you

drop them a bit of away from the school

maybe half a mile or so they walk in a

group we're wearing a hybrid Tabard said

that they're safe on the roads and they

might burn an extra twenty or thirty

calories a day at one level one might

say twenty or thirty calories a day big

deal what's this really going to do well

actually I think if you can find five

six or ten other things where those kids

burn 20 or 30 other calories a day

that's two or three hundred calories and

that's that really is a big deal so I

don't think it should be dismissed

merely on the fact that the energy

expenditure of this intervention isn't

so much but my sense is that some of the

more important impacts of something like

a walking school bus may be wider system

effects the fact that if you have a

cohort of children who get used to

walking to school every day they get

used to the idea of walking whatever the

weather snow rain windy they can just

get used to it it normalizes walking you

might get a cohort of parents who are particularly

particularly

keen to make sure that those streets are

safe for their children to walk on they

might vote for different politicians

people who want safer streets lower

speeds and so on and so forth

and you might get a cohort of children

for whom because walking has been

normalized they not all of them but a

proportion of them might be more likely

to walk during other aspects of their

life as they get older and older and if

we were to design this intervention

thinking about that we might not want to

put them in high visibility tabards

because normal people don't wear high

vis tab odds to go for a walk we might

want to normalize walking rather than

denormalize it through the

understandable safety conscious approach

that we take but it might actually be

counterproductive if we're trying to

think about a long term system effects

of this kind of intervention so if we

come back to the Swinburne diagram I

used earlier that shows the range of

actions that can be taken from upstream

to downstream what we're aiming for with

this work is is not to stop the kinds of

interventions at individual level on the

right but actually just to rebalance the

distribution keep doing the individual

level stuff but let's move upstream

let's think about the ways in which we

can promote more and bigger changes to

affect the environment in which people

live in equitable fair ways that help to

reduce inequalities and the particular

focus of the work that I'm involved in

with with Jane and others at the Health

Foundation is particularly to look at

the bar there that relates to the

evidence base but I'm not for a moment

pretending that that's the only bit of

this that needs to be done there is a

whole host of other things that need to

be done including the practical actions

at local level that Jim will be talking

about in a minute but the particular

focus we've had here is to think about

the role of academia the role of

research in rebalancing that

evidence-based so we move away from

producing evidence on the things that

are easiest to test where you can do a

randomized control trial with an e-2

cohort of people over three to five

years and come up with some results and

think more deeply about ways in which we

can generate Messier evidence that that

moves upstream one of the factors in

this that has come up from some work

that I did with colleagues from nice was

to look at the kind of evidence that's

required to make a decision because the

real world out there is having decisions

made all the time but also often in

public health I think we we say we need

to wait until we've got good enough

evidence a high quality evidence to be

able to act and I see this is a bit like

the difference between the civil and the

criminal law burden of proof all too

often we say we need to wait for a

Cochrane review or or something like

that we're demanding a criminal burden

beyond reasonable doubt when actually if

a decision is going to be made anyway

perhaps we should be looking at a civil

burden of proof the balance of

probabilities on either side of a

decision so not just what's the evidence

for what I want to do what's the

evidence for what the other people want

to do what's the balance here and it may

be rather poor quality on both sides but

is it good enough to help us make a

decision and all this has led to some

work that a group of colleagues and I

have been doing and we've had a paper

published over the summer we're now

trying to develop this further we're

writing some more academic work and

putting in research proposals where

we're building these themes in but

unless this has practical application

I'm not very interested in continuing it

so what we really need to do now is move

from this theoretical argument and

making the case to turning this into

practical action there's a set of

conclusions from what I've been saying

but I guess of these I think there are

two or three things I've pull out one is

really to emphasize this point that our

interventions within complex systems all

too often are we think about them as

like hitting a nail with a hammer when

actually what we're doing is is

introducing shifts perturbations changes

within a system and some of the

consequences will be unintended and back

son wanted and we need to be prepared

for that I'm also well aware that much

of the talk about complexity can put

people off and sometimes I think we

should be keeping these it's a bit like

the difference between what's backstage

and what's front-of-house in a theatre

we can have the messy stuff backstage

but let's distill that into something

that's a bit smarter front of house and

I guess finally I'd like to come back to

the theme of time

let's stop just looking one step ahead

let's think about where we really want

to be what's our 20-year vision how do

we translate that into a five-year

strategy to fit a political cycle for

example and what what are the one or two

things we need to do now so 20 a vision

five-year strategy one-year plan and

they should all be aligned thanks very

much thank you very much indeed Harry

particularly for giving us such a clear

sense of how we need to understand the

complex nature of the public health

challenges but also embrace some of the

Messier evidence considerations as we

try to design and develop interventions

and to evaluate what's actually

happening on the ground okay so before

we carry on I'm just like to say we're

getting some good questions coming in

please do continue to sending your

questions as we hear from our second

speaker professor Jim McManus who will

be sharing with us his experience about

the public health problems that he faces

on a day to day basis at his local

authority and how you and others are

currently trying to approach those okay

thank you and over to you thank you and

hello everybody I'm going to try and

talk through some of the practical

aspects of how we're trying to do this

the first point I would make is that and

we're not doing systems and

hartfordshire because I'm doing systems

we're doing systems and hartfordshire

because a number of us are persuaded

that this is the approach so much of

what is going to be presented is not my

doing but it's the doing of us as a team

and the doing of us with stakeholders

one of the important points I think

Harry made for me is the crucial thing

about systems approaches is you can use

them to elucidate

problems where you can intervene and in

fact I once heard Harry say that the the

key single thing we need to realize the

about obesity is there is no key single

thing we can do about to be city there

are a number of them and so bear that in

mind as I go through these I'm going to

try and share some practical information

and also explore why it's useful to

think about these challenges in a

system's way some of the health

challenges we face now the system I face

every day is very complex and it's the

models that are too simplistic

complexity is a part and parcel of what

local authorities do and has been since

II started we just haven't always

conceptualized it in that way and I

think I see Public Health hasn't always

been as much at ease with complexity as

it could and should have been throughout

the years the house foundation has

massive experience in quality

improvement work and I think quality

improvement techniques and complexity to

systems approaches align quite well I

would say that the paradigm of the

evidence pyramid actually doesn't handle

complexity very well and Harry has

Illustrated that extremely well so some

examples are coming so the organization

I work in and for has over nearly two

and a half thousand statutory

responsibilities we have 1.2 million

residents across 37 settlements they all

want their own branch of John Lewis we

have three tiers of local government

over a hundred partners and over 537

schools you can't not do complexity in

an environment like that

it just isn't possible so complexity

approaches work much better than linear

approaches where we have really messy

organizational systems and really big

responsibilities and engineers in local

government have been doing this for 6070 years

years

you can't build a road network and

indeed our 3,000 miles of road in

hartfordshire and

it's a complex approach to maintain it

the first example I want to talk through

is about public mental health so if you

look at the graph here what this graph

is telling you is actually that as you

go through the life course the

influences on you and your health

outcomes vary in early years family day

care community and school will be much

more important than individual workplace

and community influences and family

influences in later life what that means

is that you need to see public mental

health or somebody's resilient

somebody's well-being as set in to a

range of complex factors that can impact

on them positively or negatively so I

colleges talk about vulnerability and

protective factors and these don't exist

in nice neat chains the existing complex

relationships and systems so if you're

going to do something on public mental

health for example as I'll show you

shortly you have to take that system's

approach and that's what we're doing in

our future so we have about 1300

workplace champions but we're also doing

work in schools so that's one area where

complexity approaches have really helped

us conceptualize we need to intervene

across a range of levels second area is

within that the needs of LGBTQ young

people so if you start just with

strengthening the individual that isn't

going to reduce homophobic bullying it

isn't going to reduce self-harm and

suicide attempts by LGBT young people

and it certainly won't reduce the

incidence of mental health problems

where the school environment or the

family environment or the community

environment of the problem so we've

conceptualized this as a range of levels

there's some intra personal stuff we

need to do around resilience self-worth

physical health making sure that health

professionals understand the needs of

our LGBT on people there's some work

that we need to do at the interpersonal

level of working on equality working on

behavior and working on school

environments and then there's the

environmental level of policy and

systemic training and monitoring and building

building

social norms of the tower anti-bullying

you need a complex approach for this to

work if you don't take a complex

approach you will miss things and you

won't be as effective similarly just to

look quickly at tobacco any tobacco

control plan worth its salt works on at

least six levels from the biological

level of nicotine replacement therapy up

to the policy level of smoke-free

environments and training that naturally

lends itself to a complexity model I

won't spend more time on this but you

can have a copy of these slides if you

like and they'll be on the health

foundation website later along with this

webinar but they'll also be available on

email from me so how do you work with

these complex systems I think you need

to build a framework for yourself and

that framework starts really with a

level of questioning so firstly systems

approaches can help you conceptualize

the world that you're trying to

influence that for me is the fundamental

starting place if you can't build a

picture of that world and that picture

isn't complex enough then there's not

much point starting to do anything

secondly you consider the levels of

influence of various things I've talked

about biological up to environmental but

you could talk about any level of them

the Maps Harry showed were excellent

examples of some of the influences

everybody was working on one set of

interventions on the on the right and

obesity but not on the left which might

have been more effective then I think

you need to consider the evidence

paradigm you know you don't need gold

standard meta analyses of randomized

control trials for everything in fact

for some things you'll never get them we

don't have randomized control trials for

bridges but on the whole they tend to

stay up and then finally I think you

need to refine and adapt as model as you

go along the beauty about systems

approaches is it requires you to adapt

and refine and you can do that quite

regularly so what have I learned after

five years of trying this out but

firstly this here actually is a

different style of working and

fluency and advocating systems

approaches have helped me to influence

an advocate I can argue for example

Harry's point about when the need to do

population level interventions not just

individual level interventions and one

of the great debates we have about

health inequalities is do we address

individuals or do we address populations

if you take a stress approach if all you

ever do is strengthen individuals when

the organization they work for is the

fundamental problem you will never solve

organizational stress you need to take a

systems approach

now most HR professionals understand

that so taking a systems approach and a

population approach can work in those

environments the benefit of using

systems is that they can really help you

articulate why we need a systems

approach and why we want to use that so

systems thinking becomes a very strong

tool for leadership in your portfolio it

sits alongside other tools and skills it

doesn't replace them it just becomes

something else in your armory of things

you can do and the key thing here is to

be able to be agile in thinking you're

using a repertoire of tools they become

your watchwords

so how you apply these is crucial as

well as being able to choose which ones

you do and it's as much an art as it is

a science

becoming comfortable with systems

approaches is a leadership task the

whole point of using systems approaches

is actually to reflect on the world

you're engaged in while engaged in

practice in order to change that world

so that circle of moving from theory to

action and reflection and back again or

even a spiral of moving onwards is a key

leadership task and I think systems

approaches lend themselves naturally to

being able to do that so where we are

now is an attempt at building a systems

approach to prevention in an entire

population system the first thing we're

trying to do is attempt to do

system-wide prevention so there's work

on family safeguarding which is

preventing and stopping our young people

being taken in to local authority care

or looked after and we're having some significant

significant

access in that assistive technology for

the other end of the life course looking

at our asset management how can we

actually use our land and our buildings

to build housing that keeps people

independent as a form of long-term

prevention looking at our contractors

what can we do with our contractors to

reduce non communicable diseases to

prevent people becoming ill as they go

through their life course there are a

range of things that we want to do our

the range of things that we've started

we can't do everything so we've picked

six or seven areas and those are some of

them where we think if we start we'll

have some long term as well as some

short term effect illustrating Harry's

point about the three levels down to the

one-year point plan we're using systems

approaches to understand and prioritize

how we act and actually as a

prioritization tool systems approaches

have been really helpful for us the key

thing though is you need to refine and

redevelop this this brings me I think to

another key point about this in front of

the thinking if you're using systems

approaches and are working in the

complex system you need to behave a bit

like a conductor bringing together a

range of different instruments of

players all playing different signs to

play together in some form of harmony

sometimes you need to disrupt that if

the system is really dysfunctional but

unless you are working in that approach

using that symphonic approach you're not

going to get the same outcome as you

would if you were using that approach

and more importantly you won't see any

benefits over a very traditional let's

just do what the evidence says we can do

where the evidence takes us beyond

reasonable doubt approach so you either

go in this or you don't go this you

can't be half-hearted you have to take

the plunge I think the whole foundation

can do a significant number of things

here I'm aligning some of that quality

improvement insights and tools can

really help you use systems approaches

there's a very good book just published

by disserving U which is aimed at

researchers and academics it talks about

methods for systems and using complex

systems things like Network analyses

there's other things really practical

tools although it seemed as an academic

and research audience it does have

application by the same token some of

the work that the Health Foundation has

done with systems is also very useful

and I advise you to look at their

website so I'm going to finish off with

what I call my golden rules and these

are provisional they're the fruits of

five years of trying this approach and

there are two sides to it if you're an

academic or researcher or somebody who

hasn't worked in a local government

environment don't take a deficit

approach don't start working with local

government by assuming that you know

better than they do because that's a

surefire way of winding them up and

getting nowhere

actually there are Ritchie's everywhere

and you can learn from the way they do

things as much as they can learn from

you so spend some time in and with local

government before we pontificate about

how to do it there is a great danger

that Public Health can be seen as the

boffins and there's a great danger that

Public Health can be seen as a bit

sciency and therefore actually a bit

detached from the real world the key

thing is get your sleeves all up and get

stuck on stuck in in order to influence

the system now if you're in a system I

think my key rules would be use systems

as a set of tools to orient your

practice and just take the plunge and

draw a diagram of the system you work in

and the things you want to achieve

yesterday I was sitting in a room with a

number of our senior police colleagues

looking at systems approaches to health

and mental health in particular and we

just started somewhere it might not have

been the right place but we couldn't

find anywhere better to start so that's

where we're going and it is really as

simple as that start somewhere get

people on board and walk before you can

run do some reading but do some reading

that tries to bridge the theory of

systems with the practice of systems

application but I guess there are three

key points if you're going to use

systems well use systems to

conceptualize what you're doing the

second thing is see it as a leadership

tool in our portfolio to help practical

change and the third is refine and adapt

thank you for listening my email is

there if you want to copy the slides

I don't look forward to your questions

thank you very much indeed Jim that was

fantastic really helpful to hear how you

have moved from the theory of complex

systems to very practical approaches

with some examples from your work in

mental health and working with people

from LGBTQ communities as well some of

it's his fault okay so while you both

been speaking we have had some questions

that have been sent through in response

to both the presentations I'd like to

start with this question which has been

sent in saying how can you implement

system wide complex approaches when

there are so many immediate crises that

take most of the available monies and

that need to be managed every day shall

I perhaps start with you on that one or

do you want to start with um I think you

have to do it incrementally so I can and

carve out some protected time the thing

I realized is that actually if I could

spend all my time dealing with crises I

could spend all my time just doing

immediate crises and immediate problems

or I could decide deliberately to

protect some time to do systems

approaches and that's what I did so you

allocate time to manage the crises and

you allocate time to do the systems work

and maybe the best place to start is

actually you are now analyzing why the

crises come up so often and where they

come from and what you could do about it

and a good example is section 136

admissions for mental health problems

within police situations if you actually

take a root cause analysis approach to

that or a systems approach you can

identify places where you intervene

and since we put a triage car in place

in Hertfordshire for mental health our

section 136 referrals for place of

safety orders of people with mental

health problems has dropped so systems

approaches can be used if you use them

well to stop crises well I'm I'm not

just because of what Jim said I'm always

wary to say what people in local

authorities should do it's not my job

but my experience is that systems

thinking in a allowing oneself to step

back and look at the big picture can

help to see why some of these things are

happening it's the age-old you know they

ulcer it might Kelly told it to me first

about the person who's fishing fishing

people out of the river

there's loads of drowning people where

all these people coming from we've got a

rescue that we've got to rescue them and

then someone looks upstream and finds

some idiot pushing them all off a bridge

you move upstream you can stop some of

the downstream crises happening that's

one thing so I personally when I'm faced

with those kinds of challenges I what I

like to go back and map it out what's

going on here I think the time dimension

is also really important big problems

and the one I've dealt with most is

obesity are not going to be solved overnight

overnight

there are hundreds of different things

that needs needs to be done over decades

probably we shouldn't beat ourselves up

that we're not doing them all in year

one and taking the big-picture view not

just in terms of the system but also the

time dimension I think allows us to see

that and be realistic about what one can

do at any one point in time I suppose

the next step from that is really to

think through how a system response

might look if we're trying to phase

things in terms of terms of timing which

is why if you go back to the slide I

showed that had political mandate at the

bottom there are quite a lot of actions

that won't happen until the the public

and media discourse around obesity

switches from being one of individual

level blaming

conceptualising it is a failure of

willpower at the individual level to

understanding that obesity is the

product of a whole lot of market

failures and other things that require

upstream responses so so I think there

are there are different ways in in in

which a systems approach grappling with

the complexity of it can help us to see

beyond those crises some of which you

absolutely clearly you still have to

deal with but you might stop some of

them happening maybe not now but in a

year or twos time great now a couple of

questions are coming in on the sort of

practical how do you show that

leadership that you talked about Jim for

example how can you implement sorry what

are the implications of what you've

described for people who work in complex

systems in terms of leading change and

what examples do you have about how they

can develop relevant knowledge skills

and behaviors to effectively lead to

change okay um I well what do we know

about the psychology of leadership um

it's a set of influencing tools and

mechanisms that's essentially leadership

in one sentence and different tools and

mechanisms work in different situations

so let's start with our first principle

and I think you can draw a road map or a

road map with various bits on it so the

first thing is um identify what it is

you're trying to achieve and then start

to win hearts and minds to do it one of

the things we did to enhance Minds as we

heard you up talking to I think three

quarters of our elected members and

people still talk about that seminar and

then articulate what different and good

looks like build alliances and start

working with people I think there's a

big world of difference between the

transactional leadership styles we've

all been taught which we do need kind of

management process and there's being

comfortable with leading with complexity

so the the leadership program for the

next generation of future public sector

directors is trying to do that but I

think if you're going to be a leader in assists

assists

approach you need to be able to think

systems you need to be able to think

influence you need to have a repertoire

of different tools you need to be

adaptive you need to behave like a host

and I think you also need to actually

bring people together now the model of

leadership that's flavor of the month is

transformational leadership you know

the problem with that is it tends to be

very kind of hero leader right they are

kind of pushing ahead well you know the

one thing that makes a good leader is

followers I've always thought so I don't

think this is a transformational tool i

think this is using leadership as a way

of bringing people galvanizing people

and empowering them um we could we could

probably do another webinar or a seminar

on that but it's a different tactic

george binney's book living leadership I

think is that what it's called his book

on leadership is a great text for this

and I think a book on change which I

will dig out which was written by some

of the average faculty is great that I

think is it in a nutshell have I

answered those questions thank you we

have also a rather broader challenge

that systems-thinking has been around

for some time and what's new about the

approaches that you have outlined and

what difference will it make

can i pat start you with that one harry

please yes where we've been and where

we're moving to

so I agree the these principles these

ideas are not new there's nothing

original about what I'm espousing here

but I think what we're seeing is a

couple of things one is I think there's

a growing recognition that certainly in

the academic sphere that I inhabit the

the generation of research isn't helping

as much as it might there's plenty of

good research going on but there are

also some problems that we're just not

making enough progress on and something

needs to change and I think that is

helping to coalesce a number of

different threads here that are coming

through where there might have been disk

groups talking about this but actually

now coming together and no we managed to

get something published in the lancet

about complex systems thinking which I

don't think would have happened five

years ago so I think I think we so one

is I think there's there's a grouping of

people who are now collaborating on this

which is really helpful secondly we have

some funders who understand that there

is a problem here if the Health

Foundation absolutely being at the

vanguard you know the front of this but

not just the health foundation big

funders get it they know there's a set

of problems here that mean they're going

to have to change the way they do things

and you know some of us are helping work

out what that might look like and it's

gonna take time but I think we're

getting there and I think thirdly and

most importantly people like me are

talking to people like Jim and you guys

have been doing this in in your sphere

we've been doing it in our sphere and

now actually we're getting together and

trying to work out how to do it together

which I think benefits both of us both

groupings I think you're absolutely

right I think I have you take their knee

on their head there is a sea change you

can feel it going on the I would use the

analogy of psychology psychology has

been around forever have we used it well

enough in public health no we have don't

think we've used most of what was I

called as you can offer as well so the

time is now to actually sees what it can

bring and use it another question that's

come in touches on the fact that of

course that what happens at local local

level is in the context of national

policy setting so if there was one

activity or approach that national

policymakers could add in or change to

the policy-making process to better

consider complexity what might that be

I'm tempted to say get out of our way

and let us get on with a local level um

but I I haven't said that have I I think

it's break down the sealed policymaking

system we still have a national level

where what one Department the Department

of Health does doesn't affect the

Department of Education or others

central government is I think the worst

at joining up and that's why I think we

find at a local level more difficult to

join up because the way policies are

there was a great piece in the Financial

Times today by David Alan green in which

he was saying that underpinning many of

the political problems we're facing at

the moment is a is an overwhelming

desire for easy answers to complex

problems and I think somehow getting

over this idea that complex problems can

be solved with a series of to our

meetings is essential now that's easier

said than done and I think this comes

back to the point I made about what's

backstage and what's front-of-house I

completely sympathize with politicians

who've got thousands of things going on

and they don't want to get involved in

difficult knotty discussions of our

complex adaptive systems and we

shouldn't expect them to have to if they

want to that's fantastic but the job of

people advising policymakers and

decision makers is to distill that stuff

out and this where is welcome back to

the twenty a vision five-year strategy

or near plan we can have our 20-year

vision but we've got to work out what

makes sense within the political cycle

and what makes sense

now for this policymaker decision maker

to do now and if he or she wants to set

backstage and get involved in those

naughty discussions they're welcome I'd

love it if they were there but I

understand that it's not their job to be

there we it's our job to distill these

things out and present them so that they

make sense not just for what you do now

is your next step but where you're

heading in the long run one of the

analogies I like is the difference

between drafts and chess all too often

we end up playing drafts we say what's

the next move what's the next move

what's the next move where as someone

who's good at chess I'm not I'm terrible

but if you're good at chess you're

looking twenty moves ahead you've got a

strategy you know you will get swatted

on the way there the your opponent will

move some pieces that you weren't expecting

expecting

they'll have to adapt your strategy but

you've still got your eye on the endgame

rather than the next step thank you very

much now we're also getting some more

questions coming in picking up on what

you were describing Jim about how to

actually support the use of complex

systems thinking in a local government

and the question here is what are the

top things that can be done to build

local public health systems thinking

capacity oh well I think there's

probably several the first thing is

getting the room and do some shared

learning together about it

so perhaps take some we've actually got

a new website being set up a blog site

called systems approaches in public

health and there's some reading listed

there that would be my first step is sit

down and work out together in a room

what it is you think it is perhaps do a

training morning on it we could run some

of those if you wanted the second thing

I think is pick a problem and start to

analyze the problem using network

analysis I would say would be the easy

way in and then look at the range of

factors and work out what you could do

about them and then I think the third

thing is don't go running off to senior

managers and I like to remember saying

you need to do complex approaches this

stuff is a slow burn prepare your powder

get your argument get your soundbite

build your case and then win hearts and

minds so prepare it internally first

okay we might have time for one or two

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YouTube Transcript:Webinar: Complex public health challenges and local action