A solution to a knotty problem sprang into my mind last week. I was on my way to the local Health and Wellbeing Board and pondering why it has had so little effect. My previous thoughts on this had focussed on the problems with the health and wellbeing strategy and how it didn’t do what I thought a strategy should do. However, another aspect of the problem is the process for jointly addressing health and wellbeing issues. Part of the problem with our – and I suspect other areas’ – approach is that a hierarchical approach is being taken to a complex problem, when it needs a collective approach with distributed leadership.
That thought – the need for a collective approach and distributed leadership – emerged, fully formed (albeit based on much that I’ve read and thought about before) and even in that abbreviated form it seemed to make sense in my head, but what does it actually mean?
First, the problem. In our local area, the approach to the work on integration and partnership follows a standard hierarchical model. If there is a problem or project, there’s delegation to an individual or partnership group who are tasked with dealing with it and are then held accountable for delivery. Sometimes this is to individuals as with the joint health and well being strategy, delegated to the public health lead who drafted a strategy and put it in front of the board. The problem is that any individual may not have all the necessary knowledge and skills (about the subject matter or the process of strategy making) and in any case it requires buy-in from a wider range of parties. So the first point is that the strategy and subsequent action needs to be produced collectively. And that includes all stakeholders, not just the council and CCG. It means a slower, more messy process but one with more chance of actually producing something useful.
The second problem is trying to manage everything through a single, top down process. Programme and project management are good ways to get things done, (and, to be fair, it seems to be done effectively in my area), but it is more effective for some sorts of issues than others. It works where things are relatively predictable and within known parameters. It may work for some of the things we have focussed on locally like looked after children and management of care homes, where there is a limited range of stakeholders. There is a limit, though, to the scope of projects that can be managed in that way. If the projects are too big in scope there isn’t enough time in the meetings (or between) to manage them. So you end up with a Better Care Fund that is ensuring the delivery of a few small projects involving health and social care, but which have limited impact on the broader health and wellbeing issues facing the area.
When it comes to complex problems like getting the district being more active, improving diet, reducing social isolation and loneliness, mental health and wellbeing it needs a much broader approach to be effective. Tackling those sorts of problems needs the involvement of a very large number of stakeholders – other council departments, the voluntary sector, other parts of the public sector, private companies and the public more generally – who all need to be engaged in multiple activities. Managing that through PIDs and RAG rated performance reports is no longer viable. But it does need some sort of co-ordination or it could end up in chaos or just fizzle out.
So what does that co-ordination, or ‘distributed leadership’, look like? Some of it still needs to be done centrally. In terms of direction, given the degree of uncertainty and complexity, it needs to be at a fairly high level – broad visions and objectives. For monitoring, however, it needs as much detailed, shared data as you can get your hands on, to allow rapid responses to whatever emerges.
Most of the co-ordination doesn’t come from the centre, though, but happens directly between bodies on the ground – voluntary sector, public bodies, the private sector, private individuals etc. They need to talk to each other directly rather than looking to a central body for guidance. It is not that that doesn’t happen at all at the moment, but it happens without an overall context to ensure that everyone’s pulling in the same direction.
That sounds fine in principle but how do you make it happen in practice? What does it look like? It certainly means more large scale facilitated events with more input from participants than the traditional council meeting: unconferences, open space, post-it notes on walls, electronic voting. Technology has to play a role too, through discussion forums, social media, wikis.
It’s possible to see how it might work in an ideal world. Unfortunately the world’s not ideal. There are risks. There could be an awful waste of time. Expectations might be raised and then dashed. People’s personal and professional interests could get trampled on. There might not always be a selfless, co-operative spirit. People could get hurt.
The answer to that, surely is that it’s happening already but could be made to happen better. People talk to each other and change what they’re doing in the light of those conversations. There are already a lot of people trying to do the best they can for those they’re trying to serve. If that could just be given more shape and direction through a vision and strategy, and support via provision of even basic infrastructure like facilitated workshops and interactive websites, then it might be possible to move from management of incremental service improvement to real systems change.
[This was first published at: http://www.equwell.org.uk/whole-system-working-for-improved-health-and-wellbeing/]