Leading for Health and Wellbeing: the need for a new paradigm

Much of the government's health policy in recent years has focused on improving health and wellbeing. There have been numerous strategies, targets, reviews of progress and calls for further efforts to tackle what are widely perceived to be persistent, stubborn, deep-seated and intractable problems. Such problems are sometimes called ‘wicked issues’ in the sense that they defy easy or single bullet solutions—if, indeed, there are any solutions at all or ones of a lasting nature.¹ Wicked issues have complex causes and require complex solutions. They share a number of features most of which are strikingly evident in the public health challenges societies face, including tackling obesity, alcohol misuse, poor mental health, environmental degradation and so on. Unlike ‘tame’ problems which can be readily defined and solutions identified, wicked problems cannot be resolved through traditional linear, analytical approaches.

Wicked problems: There are many examples in public health of wicked problems. A good example is obesity, especially in terms of its multiple causes, the absence of clear solutions and the range of organizations needed to address the problem. The Government Office for Science's Foresight report demonstrates just how wicked a problem obesity is with all the features listed above in evidence.²

• are difficult to define clearly;

• have many interdependencies and are multi-causal;

• can give rise to solutions which have unforeseen and/or unintended consequences;

• are often not stable;

• usually have no clear solutions;

• are socially complex;

• rarely sit within the boundaries or responsibilities of any single organization;

• involve changing behaviour.

The need is to see such issues in the round—that is, as whole systems and not as a series of discrete concerns or silos which can be targeted and picked off individually. As the Foresight report makes clear, the obesity epidemic cannot be prevented by individual action alone and demands a societal approach involving action at multiple levels from the individual to central government. Hence, the importance of adopting a systems-wide approach to tackling obesity, redefining the nation's health as a societal and economic issue and giving a higher priority than we do, despite all the rhetoric, to the prevention of health problems. In their call for political epidemiology research, Gil-Gonzalez et al.³ argue that mainstream epidemiology ‘continues to consider health as apolitical and applies a definition of health that is centred on the individual illness rather than on society health problems’.

The problem is that a systems approach is not encouraged or even made possible as a result of the way in which we organize, lead, manage and regulate our policies and public services.⁴ Public health has suffered greatly at the hands of such a dysfunctional set of arrangements and has proved virtually powerless to confront and adapt it to a more relevant and appropriate systems approach that is in keeping with the nature of what needs to be done at various levels to get traction on wicked issues.

Perhaps, the most obvious manifestation of the dysfunctional nature of existing arrangements is the difficulty of making partnerships work. These have been reinvented numerous times over the years but all the efforts share one central feature—they are superimposed on a fragmented and largely tribalistic set of arrangements characterized by different cultures and ways of conducting the business. Despite this, and rather puzzling given all the evidence from previous failings in partnership working, there is a naive assumption that the new joint structures overlaid on these encrusted organizations and working arrangements which have endured for decades will somehow be different and show miraculous results and in double-quick time. Little wonder that the evidence, such as it is, shows that partnerships may be contributing little to better outcomes while absorbing significant resources in terms of time and effort on the part of practitioners at various levels in the NHS, local government and third sector.⁵

There are signs that existing attempts to improve partnership working are insufficient and that a different approach is needed. Joint director of public health appointments are an example of a new approach as is the introduction of comprehensive area assessment which takes a whole systems perspective. But both these initiatives remain untested and whether they can succeed in overcoming the barriers that exist to joined up working remains uncertain. Elson,⁶ for instance, in his critique of the way joint posts have been established concludes that although a joint director of public health appointment ‘may be a necessary condition for making significant progress’ on health improvement, ‘in isolation it is not sufficient to deliver this outcome’.

A prerequisite of the leadership challenge facing public health, therefore, is both to understand the nature of the policy and organizational context within which health improvement and wellbeing are being promoted, and to encourage and shape a new way of tackling the problems that have been well, and endlessly, described. Public health has always been a frontrunner in eloquently and painstakingly describing the problems confronting it. But such application and determination is less in evidence when it comes to acting on the evidence.⁷ Here, there has been something of a leadership vacuum. This is not the fault of any single person or group but reflects the dysfunctional system described earlier which is not fit for purpose. While inspired leaders may surface and persevere against the odds and effect change to a degree, they do so working against the grain and their efforts may prove short-lived. There has to be a better way and there is. Leaders in public health, both those in post and those aspiring to them, need to be equipped with the insights and skills which will enable a complex adaptive systems improvement approach to become embedded and, in turn, allow transformational change to occur.

A new leadership paradigm

The shift to a complex adaptive systems approach may be littered with obstacles and barriers because it seems so alien to the prevailing orthodoxy in health policies and structures. But if it can be made to succeed, it will prove liberating and trigger changes that are currently trapped in structures that are ill-adapted to their pursuit.

The leadership challenge is therefore 2-fold: first, to help bring about a paradigm shift, and, second, to ensure that such a shift produces results in terms of outcomes for better health. To succeed, it demands a mix of both transformational and transactional aptitudes and skills. A new national leadership programme has recently been launched to help meet such needs. Derived from similar programmes run at regional level, it is a collaborative venture led by the Improvement Foundation working with Durham University and the Local Government Association's Improvement and Development Agency (IDeA).⁸ The framework for the programme is based on three interlocking circles labelled Health and Wellbeing Improvement Systems, Leadership, and Improvement Knowledge and Skills. Their interaction results in improvements in the public's health. Each component making up each of the three circles has an evidence base supporting it drawn from the literature on policy analysis, leadership, organisational change and implementation studies.⁹

Possibly, the key leadership skill most urgently needed is political astuteness. This is because leadership is situational, and equipping leaders to fit the context is essential.¹⁰ Political astuteness is necessary at various levels but perhaps especially in challenging policy failures and advocating a different approach as outlined above. It could be that one reason why adopting a systems approach to public health issues has been so difficult is because of the absence of political will in tackling such problems. The failure may lie in governments preferring to regard such problems as being ones of individual lifestyle rather than being socially or structurally determined. Hence, the easy option is always to direct interventions to changing individual lifestyle rather than to reducing the health gap between social groups that continues to widen, despite the efforts of government. Leading for improving health and wellbeing means being acutely aware of such policy weaknesses and endeavouring to build alliances for a new approach. It demands political will and commitment which means recognizing and confronting power and exerting influence. Only through such means, and through seeing public health problems as examples of complex adaptive systems, can successful inroads be made into wicked problems. Leaders in improving health and wellbeing therefore need to be both politically aware and skilled in systems thinking. Failure to appreciate the significance of either of these elements is likely to end in disappointment.

Conclusion

As long as we persist in wrongly perceiving the present difficulties in public health achievement to be solely the consequence of an absence of appropriate skills and competencies among the present cadre of DsPH and others in senior positions whose job is to give meaning to health improvement and wellbeing, then we will not make the required breakthrough in delivery and impact. We have to shift the paradigm to allow a new approach to improving health and wellbeing to take root. That also requires leadership. But there are tools and approaches available to guide the change process.

Perhaps, the biggest impediment of all lies with central government policy-makers and their advisers who, for all the talk of ‘modernisation’, appear not to understand what this has to mean for improving health and wellbeing. They remain stuck in an outmoded managerial paradigm and, despite mounting evidence testifying to the failure of such an approach, seem unable to abandon it. But abandon it we surely must if we are to make real and sustained progress. It is perhaps the most important challenge confronting public health leadership as we near the close of the first decade of the twenty-first century and one that cannot be allowed to fail.