Transforming public health. What does public health 3.0 look like.
Everyone else is “transforming”, why shouldn’t public health. Having been asked about what transforming public health would actually look like, here are one or two of my personal thoughts. I’ve been a little provocative:
The main domains and principal functions of PH remain as they always were – Health care, health protection, health promotion, health intelligence.
The opportunity of transformation. What I perceive public health has to “do”.
The integrated model gives massive opportunities to really transform public health – maybe a once in a generation opportunity.
Here I define transactional change as ‘doing the job better’ and transformation as ‘fundamentally redefining the job, then doing that better’. Given the opportunity we NEED to not blow it! The blended model is a real opportunity to get a whole organisation focused on outcomes in a way the “island model” may never achieve.
The scale of opportunity is huge. It’s up to us to grasp this. This is a massive cultural challenge for the profession. I think we are up to it. First we have to stop feeling under siege, under threat, at risk and unloved.
Right now, above all, we need innovators, thinkers-outside-the-boxers, idea mongers, thought-scavengers and system workers. We do not need turf-protectors, back-watchers and box-tickers (thanks Roy Lilley for that line)
Its up to us to engineer big conversations – to grip new agenda that NHS based PH hasn’t interacted with meaningfully for 30 years. Economic development, transport, planning, regulation skills etc. Go and play with new people, you’ve a lot to add. Influence others. Be influenced by others. It’s a two way process. Help support the agendas others have.
We need a new approach, building on the progress we’ve made but ready to reach into the areas where Sheffield needs the population approach.
Develop new thinking, new skills, new philosophies, new stakeholders.
Bring new stakeholders into the business of public health. Critically, get members and the public engaged in the activity of PH. This is a two way relationship, and there is huge added value in this that is not being optimised currently.
We need to be clear what the ask is of us, and what the expectation is. This is my job. It’s also your job. Again, it’s a two way process, you should also ask of others also.
We need to decide how “safe” we want PH to be? “safe” might not achieve maximum impact. We should determine how radical we want, and are able to be. We must achieve the right balance between challenge v support; analysis v practical help; evidence v innovation.
Skillsets we want in PH 3.0?
I am mindful of the ‘deskilling’ argument (its been expressed a few times). The counter is one of – pick up new skills whilst honing existing ones. The skill sets that ‘PH types’ should have are well defined by the Faculty of Public Health and Skills for Health.
Public health skills and expertise in activity such as data analysis, evidence gathering, action planning, evaluation and outcomes-based commissioning can support system-wide reform.
These core skills remain – evidence, epidemiology, economics, evaluation, ethics – but applied in a new paradigm. However, public health works to a definition of health coined in the 1940s, a suite of competencies set in the 1970s and call ourselves change agents for the 21st Century (Dom Harrison, Blackburn). The system and skillset needs an overhaul.
Some of these skills we have in abundance, some we need to develop (or get from elsewhere)
- Stats and epidemiology – applied to health and well being
- Marketing in all forms – all forms of media; campaigns (positive and negative messages – take from NYC). Reaching out to get messages out in a way we haven’t historically been good at.
- Communication of science, understanding and saviness about risk and risk communication. Media advocacy, crisis communication – these skills as as important as “epidemiology” or “environmental health”.
- Media saviness – harness the media to better communicate with a range of audiences. Simplify the message. Clean information is an important and underused tool in PH – as important these days as clean water?
- Policy analysis and evidence based policy development
- Legal analysis and skills – what do we have the legal mandate and authority to do.
- Evidence synthesis – not just “traditional medical evidence” but a much broader paradigm of evidence.
- Reinvest and refresh our social science skill set – Qualitative research (or in everyday terms – “asking folk”)
- Philosophy of Science
- Relook and refresh around behavioral Sciences
- Complexity Analysis, Methodological and research skills for the complex real world
- Policy Analysis and Influencing skills
- Tenacity and courage – Public health is a contact sport. When it offends powerful economic or other interests, they often hit back
So develop your old and existing skills by all means, but get some shiny new ones also (and no there’s no money to go on expensive courses – sorry)
So keep your technical skills. But develop new skills in order to 1) hold the whole system – commissioning and providing – to account for outcomes, 2) connect and knit things together that may not otherwise get connected and 3) put “health” into new agendas.
whatever way you cut it the “technical skillset” comes back down to the following:
- evidence – what does the research base tell us are good things.
- need (epidemiology)
- value for money and return on investment (economics)
- ethics – helping define the “right” thing to do
- evaluation – if there’s no research base, undertake a proper evaluation
Use these skill sets to help make the case for upstream – this IS your area of expertise. There are economic, and other arguments that this is the right approach. Support those who want to develop skills in this area
the “Medical vs social model conversation” crops up a lot.
We are moving PH from a clinical / medical construct towards a social movement / social justice approach. This is good and creates opportunity.
In both upstream and downstream thinking, the medical model of health and the social model are both important, in different ways, to different stakeholders.
The former is still important and should be nurtured, we will loose opportunities by neglecting medical and lifestyle interventions with short and medium term return. We also need to occupy space in the latter.
Moving away from the medical model is challenging, but its both the right thing to do and an essential strategy for survival.
“but we are special” or “different”. I hear this a lot.
No we aren’t.
I’ve heard many stories that public health in local government is not yet normalised, not yet fully integrated. There are some areas where it works very well, some less so. This is work in progress, and it’s slow work changing a nearly 40 year organisational culture and history.
(The fact that PH is “reported differently” perhaps impedes this integration. Why is this the case, is there justification for that separate reporting line warranted in a matrix type of organisation (no is my view btw). We should have complete transparency about the totality of the PH Grant.)
Regardless of what we may think (and yes we do have a “downtrodden, nobody understands us” attitude)…. We ARE wanted, and our skills ARE valued.
We do have passion, and a specific set of skills & perspective that are wanted, this doesn’t intrinsically make us “special.
Move away from the “professional” silo – keep those skills, but apply them in new places. Don’t be shy. Don’t advise others from a distance, ‘get stuck in’, working alongside others, both strategically and in front.
There’s a critical point here – public health is not ‘owned’ by people that have ‘public health’ in their job title. It’s a broad church with a very diverse set of people having a stake in this. Work out who they are, where they are, what skills they’ve got and what you can add.
Science versus getting stuff done
Don’t be overly precious about the science when it’s not appropriate or the science is flaky. Science is only one element.
The important thing is to get positive change done.
You need to provide clear and tangible help to difficult decisions, move things on.
Be smart about counterfactuals – for example air pollution increases with new development, but there’s a trade off with jobs and employment. Air pollution kills people, but poverty and joblessness also kills people.
Given pressure to deliver innovation take a practical approach while still maintaining the integrity of evidence-based analysis. Evaluate everything. Learn from success and failure. Take measured risks.
Your role around system leadership.
You have a role around “linking stuff together”. Go forth and do it.
Act as an ‘honest broker’ between the NHS and the rest of the local authority.
The toolbox available to achieve this is pretty much the same The skill set we need to execute the tools needs some honing. Ways of deploying those skills include technical analysis, facilitation & convening, leading and narrative shaping.
System leadership is about linking stuff together at large scale, beyond organisational boundaries. It needs more than hierarchical authority; and power rests in behaviours, trust and relationships.
The talents of Public health superheroes have already been identified. Develop those talents.
- Mentoring nurturing
- Shaping and organising – administrative
- Networking and connecting
- Knowing and interpreting – not the technical badges, but the selling a story
- Advocating and impacting – population approach.
Consider how to use these five questions in system leadership
- Who is my ally. Who influence them, have coffee with them.
- What help to they need – meet them where they are at. Help them, they will help you.
- What motivates the players – see what floats their boat, what do they see as the next big thing.
- What do we know – boil it to a killer fact.
- What is the purpose – why are we meeting, what do we want out of the meeting.
Ask difficult questions.
You have a responsibility to ask awkward questions. This isn’t to be awkward for its own sake, but to get people to think about broader agendas.
- For example – what is the purpose of the NHS? To keep people who are 87 alive for a week or to extending lives and improving quality of life. What is the social purpose of the NHS…..why does it exist.
- What is the purpose of economic growth – to create lots of unstable, insecure jobs or to to a broader sense of well being.
Change the language of public health
well being interventions in the broadest possible sense – social model, not just “health”.
Moving away from a language about ‘health’, ‘public health’, ‘social determinants’ may be important.
Language defines reality, inappropriate use of language also allows us to retract into silos.
There is a case for deliberately moving away from a language that public health is about providing / commissioning services towards policies that prevent avoidable early death and suffering, and maximise well being – this is a fundamentally different emphasis.
Organisation and responsibilities & the money
The cluttered public health organisational landscape remains. We can help clarify this esp around organisational roles and responsibilities and how they join up.
The “PH Grant” – is tiny, if we really want to upgrade prevention we need to influence the agendas of the big spending organisations. The PH grant may substitute for other SCC funds, IF it achieves the transformational change.
To quote Rutherford – “we’ve run out of cash, now we’ve got to think”.
Obviously we need an unrelenting focus on value – what outcomes are being bought for the £ we spend – the return on investment is all. But there’s also a case for a level playing field – the evidence consistently tells us that many preventive interventions represent great value, when you are challenged in this, counter challenge with poorer value investments currently made in the area. Is it ok to challenge a small investment in something incredibly valuable when a huge investment that delivers poorer return on investment is unchallenged
PH will never be in control of large chunks of cash as “the commissioner”, so live in a post cash world. The job becomes one of holding the system to account for whether outcomes are delivered for the resources put in
We should continue to have a role around being system connectors, bringing different ideas and perspective. We should continue to push for investments based on evidence of effectiveness, impact and value for money, and push for evaluation where there is uncertainty.
We should seek to increase the range of stakeholders engaged in the entity that we call “public health”. Develop new interests, new skills new ways of looking at the world and new ways of linking things together to better utilize the resource that’s already committed to maximize health.
PH remains at intersection of lot of agendas, there is no single approach can be identified as the basis for a highly effective public health function. If PH3.0 is around accountability for outcomes, then our role becomes to question and support the use of £xxxbn of public money to improve outcomes and address inequality.
Yes of course some transactional stuff remains (eg the mandated functions). Arguably others are better placed to deliver commissioning of sexual health.
Focus in on the things that we are best placed to address, and support others that are better placed to do but with support and insight from PH types.
Be creative with the Grant. The PH Grant funding can be used to seed or support activity that contributes to health outcomes in a wide range of areas – children’s centres, road safety, green spaces etc. may gain a place as a full partner, rather than an arms-length advisor. Its my job to tell PHE you’ve spent it appropriately. Be innovative.
So – in summary
if we don’t change- and it would be so easy to stay as we are, to ignore the new challenges, to just retreat to our comfort zones- if we don’t change – we will be vulnerable to the future and never quite secure.
But if we change, if we become the change, if we lead this change
this city will benefit from the insights we have, from the leadership we can offer and from the passion we share for health – health as an enabler of education, or employment, of enterprise, of progress, of fulfillment.
We will be harnessing the efforts of society to improve health, tackle inequalities and prepare our city for the challenges ahead.
We know public health has that potential- we have to change to make that real.
Above all, be yourself, tell the truth and remember to honestly represent what you feel is best for the population you serve.
These are only my thoughts
I’d welcome your views.
Thanks as ever to @smithkjj for inspiration and ideas.
LGA. 2016. Public health transformation three years on. Extending influence to promote health and wellbeing
Public Health 3.0: Time for an Upgrade. DeSalvo et al. AJPH April 2016, Vol 106, No. 4
Talents or public health superheroes http://jpubhealth.oxfordjournals.org/content/early/2014/02/09/pubmed.fdu004.full.pdf
the Faculty of Public Health sets out the broad skill base that a person registered (UK PH register or GMC register) public health specialist should have
Skills For Health sets out a knowledge and skills framework more broadly https://www.healthcareers.nhs.uk/about/resources/public-health-skills-and-knowledge-framework