A possible shape of a Joint Health and Wellbeing Strategy
Having considered what a strategy should contain, suggested that many Joint Health and Wellbeing Strategies (JHWS’s) don’t seem to be to be properly strategic and speculated on why that might be, I now want to show what the essence of a strategy might look like. This won’t be perfect, it’s not the whole strategy and it’s not how one should be produced: it’s only designed to show that a different perspective and approach is possible. Also, although this is long (for a blog), it still only sketches the proposals, missing much of the necessary, supporting detail. There is a diagram illustrating the elements of the strategy towards the end of the blog.
Vision and objectives
The strategy has its sights set 10 or 20 years ahead or even longer, although there is much more detail about the earlier part.
The aim is to have a much healthier, happier and less unequal population. Many of the things necessary to make that happen are already being done. However there are some big prizes currently unexploited and beyond our reach using current approaches.
In this new world, ten or more years hence, the vast majority of people will lead healthier lives: they will have plenty of physical exercise, eat healthily, have no or minimal substance abuse and have plenty of social contact. They will also be much happier. The proportion of people who are obese will be, say, 1% and those overweight, 5-10%. Health and public services are focussed much more on prevention, early detection and intervention. Technology is used to best effect to support this, and the social and physical environment support rather than hinder it. The current trends of improvement in medicine and health care will have continued.
This new world is not more expensive or difficult to sustain than our current situation. Prevention is generally not more expensive than cure. But it won’t happen automatically. We are not currently on a trajectory to reach it. So what are the major obstacles and impediments to achieving it and how do we overcome them? There is no single, simple solution. What follows are just a few ideas from one person. They may not be simple or guaranteed to work, but they show that such change is not impossible.
Moving from treatment to prevention
‘Prevention’ features prominently in most local health and wellbeing strategies and also in national plans. However, there is seldom, if ever, a route identified for achieving a transformational level of change in it. To do that, it has to go beyond individually-based public health programmes on things like stop smoking and help for the very obese. There are three main elements to prevention. The first is the context and environment, which is discussed further below under ‘social determinants’. Secondly, there is also a need for services to shift from treatment to early intervention and prevention. A key problem here is that it will take time for the benefits of prevention to feed through to less treatment of ill-health so this requires additional resources to begin with, to kick start the process. An approach to address this is considered under ‘resources’ below. The third aspect of prevention is increasing healthy behaviour amongst the public – physical activity, diet, reduced substance abuse and social connection. This is considered in the next section.
Producing more healthy public behaviour
The first problem is how the behaviour change necessary can happen. The first answer is to do with context and environment. People had healthier weights and diets in the 1950’s and that was not because of some difference in will power or human nature. That doesn’t mean recreating the 1950s, but it shows that context matters. Many of the changes necessary (e.g. in food manufacturing and retailing) are outside local control, but there are still things that can be done. Some of these ‘social determinants’ are discussed further below. Another answer comes from looking at how behaviour changes – not usually as the result of exhortation, but rather in response to the environment and being influenced by others. By targeting and working with the key influencers and ‘super-spreaders’ an epidemic of behaviour change could be produced. This would involve identifying the influencers (both individuals and groups), making it easy for ideas and behaviour to spread (such as by providing opportunities to bring people together, virtually as well as face to face), providing the supporting information (which provides the rationale and justification to people for the changes they were making anyway) and publicising the numbers so people feel they are part of a wave of change.
Relationships are also important and another strand of work would be about building and developing social cohesion and social capital. This is part of behaviour change and other aspects of the strategy discussed below, but also has substantial health benefits in its own right, by reducing loneliness and increasing mutual support, so affecting mental health. As well as bringing people together, perhaps there could be longer term goals about the way people relate to each other, creating forums and mechanisms for discussing differences courteously. This could include the development of ground rules, increasingly adopted by different groups and meetings, which allow for strong disagreement but within the principles of fair, courteous, open, transparent and non-conflictual debate.
The issue of resources
A major obstacle to progress is resources. While the end point we are trying to reach may be no more expensive, it requires resources to get from here to there: to do the things necessary to produce behaviour change, to spend more on prevention before the benefits have fed through to reduced demand, and so on. After a decade of austerity and massive cuts to local authority budgets, the idea of squeezing out more resources may seem fanciful. However, as a society, we live in plentiful times, in total. Options might include crowdsourcing, a local lottery, fundraising campaigns or a local community investment bond with any returns coming from future savings. Although many people who care for others are already overburdened, there is still untapped potential in the input the public can give on a voluntary basis. Ways of tapping into those resources would not offer a solution in themselves; it’s unlikely to be enough. But they could be used to kick start a virtuous circle of investing in things that will produce a pay back, while also improving health and wellbeing, with some of that payback then invested in other things that will produce a return, and so on. Part of that process would require accounting for returns and investment and possibly pooling resources, for which the Better Care Fund is already available as a vehicle.
Those two things, an epidemic of behaviour change, and a virtuous circle of reinvest to save, plus all the detail underpinning and surrounding them, could be enough to produce the change required, over a long period. However, there is more to be done to make those things happen and also to produce other valuable changes.
The foundations supporting change – public involvement, collective commitment and long term social accounting
The first is much greater involvement of the public. The majority of prevention and healthcare is done by individuals with family, friends and other help. The public need to be seen as equal partners with public services and others in the strategy. They also need to be actively involved which will require mechanisms to be set up to do that. That includes co-production in design and delivery of services and collective endeavours such as time banking. Governance arrangements are needed that build the public into decision making. There should be transparency so everyone can see what is happening. An infrastructure needs to be set up, on-line and face to face, for collective discussion and decision making. Those developments will help produce ownership and commitment but also good ideas and sharing of the workload. It should also support an ongoing shift from treatment towards prevention, since much prevention takes place outside of formal health services through self-help and peer support.
Another thing which will support the change is ‘collective commitment’. There are two intertwined parts. The first is the ‘collective’ bit which requires partnership across the public sector and between the public, private and voluntary sectors and the public. The second, is signing up to, or contracting, to work together on the strategy over a long period of time. There are specific things that can be done to support this, such as protocols, cross-party agreements and financial and governance arrangements, but it will also require leadership, vision and drive. It will also be supported by the development of trust: slow to build and easy to collapse. It means addressing fundamental issues of partnership such as conflicting interests, free riders and the problem of who pays and who benefits (where pooled budgets may be one part of a solution). It is also possible that moves in this direction will be made nationally (e.g. merging health and social care).
Something else associated with collective commitment is long term social accounting. This is partly about a long term perspective, thinking about and valuing changes that may take decades to produce (and recognising other changes that may happen over the time period). It also means accounting for the gains, taking account of a range of social costs and benefits (for which there are established methods, such as those used by the Treasury) applying relevant discount rates. Taking account of all costs and benefits, at its simplest, means counting all public service costs, for instance, if a local government initiative produces reduction in crime and demand on the health service, then those benefits need to be included in the calculation. However, it also means valuing those things that matter such as human happiness and wellbeing. There are, of course, many barriers to this, including national regulations and financial arrangements so it is a long term objective to be planned for.
With a collective commitment and gradual release of resources, there can be a move – slow at first, but gradually building up speed and momentum – from treatment to early intervention and prevention.
Changing the context and environment – social determinants of health and wellbeing
It is also necessary to change the context and environment in which people live, the social determinants of health. Even though we have more to learn, much is already known about these. Some of the ‘easier’ things, which are already being progressed to a greater or lesser extent in many areas, are better cycle and walking routes, encouraging walking to school, access to green and blue spaces, location of fast food and gambling outlets, better housing etc. Substantial progress on many of these will depend on more resources being available.
Progress on them does not need to be purely top down and centrally controlled. Professionals can be encouraged and supported to get on and make changes which we know will work. However, there will be a need for co-ordination and decisions will be needed on where to spend money and the order in which to do things. There are a number of factors which will influence this, including rates of return, balancing risk and return and ensuring shorter as well as longer term returns both to allow for reinvestment but also to ensure continued commitment to the approach – if people can’t see any good coming out of it, they may give up on it.
Co-ordination (supported by the ‘collective commitment’) can help ensure actions produce more than the sum of their parts. For instance, development of cycle paths should be done in concert with employers providing facilities for people cycling to work (safe places to lock up bikes, showers and changing facilities etc.) and the ‘epidemic of behaviour change’. It also links with other benefits and policy objectives such as reduced car use and pollution. So, concerted effort is likely to require the involvement of a wide range of stakeholders: public health, leisure, transport, environment, education, CCGs, hospitals, GPs, voluntary organisations and individual members of the public. And it will only happen if everyone believes everyone else is going to participate, hence the importance of its place in the strategy and of collective commitment.
Some of the social determinants will be much harder to change, such as many of the economic inequalities that drive health inequalities. There will be political differences (including over the role that economic inequality plays, the responsibility of individuals, liberty vs equality and the best ways of making changes). Also, many changes will be outside of local control (e.g. benefits, minimum wage, employment law). Nevertheless, some change will be possible, even if much of it is done on a voluntary basis powered by ‘nudges’ and collective pressure (e.g. schemes that publicise and therefore reward local employers for their pay and employment policies). This is clearly an area which will rely on success in ‘collective commitment’ and should therefore be provisionally programmed for some years into the strategy.
Another factor which will contribute to the strategy is investment in technology. This is a key source of productivity improvements. At the local level this will largely be about application of existing technology. With the rapid advancements in digital technology there is a lot of catching up to do, particularly in the health service, such as IT to support organisational processes, AI underpinning diagnosis, telehealth and wearable technology. Such investment can increase efficiency and effectiveness generally, but it can also be an enabler for other aspects of the strategy, such as involving the public. There will also be opportunities for supporting and applying other technological developments such as in AI and genomics, where a longer term perspective on returns will be important.
Targeting and proportionate universalism
Another strand of the strategy, and something already done to some extent is targeting and proportionate universalism (i.e. addressing everyone but paying particular attention to certain groups). Focussing on children, from conception onwards but particularly 0-3’s will clearly have a substantial long term effect. Also addressing the needs of particularly vulnerable groups (such as the homeless, disabled people and looked after children) will have significant impact on them and help reduce inequality. And for some groups, such as, perhaps, so-called ‘troubled families’, being able to halt cycles of decline will not only be better for them, but also a lot more cost effective than constantly dealing with the problems created (although progress to date illustrates the risks of ‘copy and paste’ solutions, mandating an approach across all areas). Other groups worthy of early attention include young families (alongside the work with their children) and ‘pre-older’ people – getting into habits and behaviours to do with physical and mental exercise, diet and social contact, while the motivation is there, that will later reduce things such as falls and dementia.
The final strand of the strategy is system design, including the redesign of what the health service calls ‘pathways’, changes within organisations and between them. This is partly about where you go for help at different stages of a problem but also organisational and institutional reconfiguration of services and facilities. It also means looking wider at the way things happen throughout society, from the private acts of individuals through to the responses of services. There will be opportunities here for improvement generally, but also to support the other changes going on, such as the move towards more prevention. A word of caution though: restructuring is already the policy instrument which public services, particularly health, tend to reach for first and on its own it is unlikely to be helpful. It might be better to put a moratorium on all such change for a few years, and then use it to support the changes which have already happened elsewhere.
Complexity and systems thinking
Underpinning all this is a recognition that we are working with complex systems. That means there will be a lot of uncertainty. While you need to think a long way ahead, you can’t plan that far ahead with any certainty. Instead, there needs to be a lot of review and revision as things progress. A lot of what seemed to be good ideas will be found not to work in practice. Rather than just giving up, lessons need to be learned and revisions made to approaches. Systems mapping of various sorts will also be an important technique and process, operating at different levels of detail.
A key aspect of the strategic thinking should be to identify opportunities for non-linear change such as: positive feedback loops, (such as the ‘epidemic of behaviour change’ described above); leverage where a small input makes a big change (e.g. reducing car use increases walking which benefits mental health and reduces air pollution); or gaining a critical mass (e.g. where a concerted effort to get people moving may have more effect than each agency taking action on their own, such as the example of promoting cycling, described above). It is also worth remembering that there will also be negative feedback loops which will impede progress. There are many other possible positive feedback loops. Reducing social isolation directly impacts on individuals’ physical and mental health but can also be a means to spread positive health message and behaviour and to unleash untapped resources in the community through co-production. Stress or low mood can lead to unhealthy behaviours like drinking too much alcohol or overeating, so dealing with stress has that further knock on benefit.
The strategy over time – three phases
To get an idea of how this strategy might play out over time, it might help to consider it over three phases.
The first phase would last for three years or maybe a little more. A key objective of this period would be establishing some of the foundations necessary for longer term change, in particular collective commitment, public involvement and the spend-to-save investment with pooled budgets. These are not simple one-off tasks; rather there will be gradually development with much review and revision. This is partly because of the difficulties of getting it right first time and unforeseen consequences but also because it will require changes to attitudes and behaviour. ‘Collective commitment’ might start with a simple contract signed by a handful of leaders, but will only become meaningful as more people at all levels genuinely buy in to it. As with public involvement, that buy-in is only likely to happen when people see it working well and see the benefits.
In addition to those fundamentals, there would be the sort of existing activities seen in many Joint Health and Wellbeing Strategies: recognising priority areas and shifting resources to them, even if only marginally. This also includes implementing existing good practices everywhere, from wards, to services and partnerships, to become as good as is already known to be possible.
At the end of the phase, the strategy would be reviewed and revised. That revised strategy would still be for a long period (say 20 years) but would again be revised at the end of its first phase.
The second phase would cover, perhaps, years three to ten. Some of the early investment in projects and technology should be coming to fruition with identified savings which can be reinvested. The infrastructure for greater public involvement should be established and able to be mobilised. That would include things like co-production pilots, public representatives embedded into committees and other governance arrangements and the infrastructure for distributed leadership such as online places that allow for discussion, decision and co-ordination. The culture of common purpose would start to be embedded so there is identification of areas where there is general agreement and the ability to agree to disagree in thoughtful, non-harmful ways. With some of those basics in place, a start could be made on the more ambitious elements of the strategy such as the ongoing campaign for healthy behaviour, long term social budgeting and redesign of system wide pathways. The process of moving health services from treatment to early intervention and prevention should also be well under way.
The third phase might cover years 10 to 20 and is inherently much more difficult to foresee at the outset. It might be asked, therefore, why bother including this phase in the strategy, as a new strategy would have to be drawn up by then anyway. There are at least four reasons. Firstly, the full benefits of some of the early actions will be manifested in this period, such as support for children and young people or a tree planting programme and it will be helpful to record from the outset what is expected. Secondly, some changes may take that long to be made such as major physical developments that require not just all the stages of planning, consultation and building, but also, say, opportunities arising out of land use. Thirdly, there will be changes in the wider social, technological and natural environment to take account of from the start. Much is unknown, but many changes are already following a more or less predictable trajectory, such as an ageing population, the introduction of electric and self-driving cars and climate change. And fourthly, objectives for this phase could include things which might seem ambitious or even unachievable now, but which the work in the first two phases could make possible. As well as the opportunities in this phase, there may be significant challenges which can be anticipated and prepared for well in advance.
So, what sort of changes in that phase should we be starting to plan for now? Transport infrastructure may be very different: your car could drop you off at the hospital and then go and park itself half a mile away. Will cycle paths suitable for a handful of bikes using them at any one time be able to cope with vastly greater numbers? What are the implications of a cohort of teenagers who are vastly fitter, slimmer and more equal than those seen today? With increases in AI supporting diagnosis and self-care and the increase in peer support and social prescribing do we need to go far beyond the current Primary Care Networks, to a different sort of physical wellbeing hub, and if so, how long will it take to identify and build the necessary buildings? And how is the current design of new housing developments taking account of the world we expect to see in 15 or 20 years time?
All such planning requires a good deal of caution. The world will probably not be as we expect it to be now. Things will not pan out as expected but there will also be unforeseen events (such as wars, climate change, mass migration, epidemics (yes that was in the list before coronavirus) and the singularity. Some of those may render the strategy redundant). So keeping options open will be important. But at least to have considered different scenarios should mean that some things can be prepared for that might otherwise be ignored.
This strategy is not something that could be simply mandated for all areas and ‘done by the numbers’. However, there are enough examples of change like this from round the world to give us some confidence that it is possible. The main point, though, is that so called ‘strategies’ looking only three years ahead and not planning anything substantially different from what already happens, are not going to produce these results. But taking a long term approach for where you’re trying to get to and what it might look like, can enable you to spot the blockers and enablers and with creativity it should be possible to find ways to overcome them. Implemented at national or even international level as well, it could be much more powerful, but even for a local area, substantial change is possible.
What is also clear is that producing such a strategy requires some work. It has taken over 4,000 words just to sketch this one, possible strategy. To go into the full detail required, provide supporting evidence, assess likely costs and benefits with net present value, look at alternatives and so on needs a Joint Health and Wellbeing Strategy of more than the typical 20 or 30 pages (although there should also be a simpler version of that sort of length, summarising the conclusions). The good news is that much of the work can be shared between areas across the country, whether that’s ideas on the possible shape of a strategy, bringing together the supporting research or outlining the future scenarios we might all be facing. The infrastructure to enable that sharing (e.g. Knowledge Hub) exists and has existed since the requirement to produce a JHWS was enacted (anybody fancy joining me as the facilitator of a revived Health and Wellbeing Board Group?). The world has changed since then and the context is different: perhaps some of this strategic thinking will be done at STP level, with nested JHWS’s at local authority level. The point is, it’s not too late to start thinking long term.