In the last blog, I produced a map of the health and wellbeing system – the range of factors that produce good or poor health, from social determinants to personal behaviour and treatment.  That tells you what is there, in the ‘system’, but not how to improve it. 

There is no single, simple way of discovering the best ways to improve; it is more an art than a science.  There are, nonetheless, things you can think about.

Firstly, you can try and identify what would make most difference to health and wellbeing, in terms of life expectancy, quality of life, inequalities and cost.  For instance, how many people die from various forms of cancer, other health conditions or as a result of air pollution or traffic accidents.  What things most blight people’s lives.  Where are the biggest causes of health inequalities.

You then have to think which of the changes to those is most practical and possible to achieve (a cure for cancer would be nice but possibly harder to achieve than, say, ensuring people’s housing is not making them ill).

Thirdly, when thinking of some future state which would be significantly better, you need to consider how stable or sustainable it would be – would it be in equilibrium, rather than forces dragging you back to where you originally were (after a big campaign to get people to eat more healthily, or stop smoking, are there pressures that will lead them to go back to their old ways?).

Fourthly, as well as thinking about where you are trying to get to, you need to think about what could produce the improvement.  This has to do with the underlying mechanisms of improvement, the sorts of instruments you can deploy and the interrelationships between different factors.

The underlying mechanisms include things like innovation, technology and design, discussed further below.

The instruments available to the partnerships implementing a strategy  (through the actions of constituent members as well as by the partnership as a whole) include:

• Reallocating existing resources (e.g. towards some area of need such as mental health or some form of provision, such as community health and care).
• Finding new resources, such as tapping into the goodwill of the community, issuing some form of social impact bond or making use of renewable energy.
• Investing resources, such as into technology, to produce future payback
• Redesigning systems and processes, such as the way people are treated for different conditions
• Incentivising change, through choice architecture (such as the placing of goods on supermarket shelves), competition, setting targets etc.
• Persuading, through information, advice and advertising
• Prescribing, through laws, rules and guidelines
• Learning, by reviewing what has been done and what has happened and changing the approach.

The interrelationships between factors is important because changes in health and wellbeing take place within complex systems.  Major change is often not steady but comes in waves and bursts, often as a result of some sort of shock to the system.  Being forced to use teleconferencing (such as Zoom, Teams, Google Hangout, GoToMeeting etc.) got us over the hurdle of knowing how to use it and having the confidence it would be useful.  There was also an element of having a critical mass: there’s no point in having wonderful communications methodologies if there’s no-one at the other end to communicate with.  Quite significant changes in behaviour such as the smoking ban or requirement to pick up dog mess required a combination of regulation, persuasion and peer influence: together they had a proportionately bigger effect than any of those factors individually.

Taking all those approaches into account, here are some of the improvements that might be possible and the means by which you could achieve them.

A system rebalanced towards prevention would be no more expensive and might be cheaper.  The problem is how to get there (you can’t just reallocate resources towards prevention because you can’t stop treating ill people – it takes time for the benefits of prevention to feed through, so you would need some period of ‘double running’).

Significant improvements without extra cost could be achieved by having more healthy behaviour.  We could all eat and exercise better without it costing much more (though healthy food can be more expensive and you may need clothes to exercise in).  And once we had changed our lifestyles, there’d be no reason to go back to how we were before.  The problem, of course, is that there are forces that have made us unhealthy (e.g. advertising and processed food), and the question is how we could counteract them and prevent them exerting their dominance in future?

A key way of producing improvement over the long term is through the use of technology.  Changes in technology have been the main source of increased wealth over the last few centuries, whether that is railways, the internal combustion engine, plastics or information technology.  So that is not a bad place to look for the big improvements for the future.  (Of course that doesn’t mean that if you invest in a big, new, shiny IT programme it’s necessarily going to net you great results).

While it could be thought of as a sub-set of technology, big improvements have also come through design.  Some changes have come not by new materials or machinery but just doing things in a different way.  The cost of transporting goods by sea was made dramatically cheaper by storing the goods in standardised containers.  It is easier to move your case around if it has wheels, so you can pull instead of carrying it.  Surgeons made fewer mistakes when they followed checklists.  Similar improvements can come in the way services are organised for individuals but also groups of services (or ‘pathways’) and processes between organisations.

There are also opportunities to be had from targeting implementation efforts.  Typically, a small number of people account for a large proportion of illness and costs.  Putting more effort into those people could produce more than proportionate returns as well as reducing inequality.  (Of course, this is already done to some extent, but there remain untapped opportunities for doing even more).

There are significant opportunities for improvement through co-production. Although the term is often bandied about without real justification, genuine partnerships between people and services can release resources (people doing it for themselves rather than paying others to do it), improve the design (people often have good insight into their position) and increase buy-in to processes and changes.  (However, while there are benefits to be had, there is no guarantee that there will be a net financial benefit.)

So, good places to start looking for improvement are: prevention, behaviour change, technology, design, targeting and co-production.

This, of course, is just one part of the process of producing a Joint Health and Wellbeing Strategy, but it is an important one.  There is no point in setting priorities or targets if you have no way of achieving them.  It can also take time – probably more than just a two hour workshop.  It cannot be done by a few people beavering away in a back room – it needs to include a range of stakeholders and particularly patients and the public.  And it is not a one-off analysis – the whole strategy process involves iterations between different stages: an insight in one part (such as visioning or stakeholder analysis) may lead to new ideas for other parts (like implementation methods).  However, doing this sort of thinking could help make big improvements in many health and wellbeing strategies.