Deriving areas for strategic focus in a JHWS
In my last blog, I said I would look next at what a Joint Health and Wellbeing Strategy (JHWS) might look like if resources and ambition were limited (given that my previous attempt to sketch a strategy required a considerable degree of commitment and joint working). This blog doesn’t quite do that, but it does illustrate a way of thinking that might support the analysis necessary to produce alternative strategies.
This way of thinking came from my reflections on the approach being taken locally to developing a strategy. As in many other parts of the country, this area is taking a ‘priorities-led’ approach. In essence, this means taking a long list of things that ‘seem important’ and gradually whittling them down until there is a small enough number of them that they appear able to form the basis of a strategy. The rationale is that you can’t do everything in a strategy, so you need to narrow down the areas on which you will take action. However just trying to think of things ‘that seem important’ and putting them into rank order is not sufficient. It fails to do three things.
Firstly, it doesn’t articulate exactly why you need to prioritise and so when you do and don’t need to narrow down. The reason for prioritising is that there are limited resources (money, people’s time, capital / equipment / infrastructure etc.) and attention (of senior leaders, stakeholders and the public). So, you won’t be able to find extra money to spend in all areas. And senior leaders won’t be able to give sufficient attention to manage tens or hundreds of different issues. A complicated strategy without a simple underlying message probably won’t be understood or remembered by stakeholders and the public. However, you could, for instance, ask each of the hundreds of health and local government services to go away, reflect on some particular proposition and take action within their delegated authority and budgets. So in that way, a strategy could act on hundreds of different areas at once, rather than limiting itself to a handful.
The second problem with a crude, priorities-led approach is that it doesn’t consider how the candidate priorities may relate to each other. So, for instance, promoting children’s mental health, focussing on the first three year’s of a child’s life and supporting vulnerable people to live healthier lives overlap each other and would be best pursued as part of a bigger picture of change.
The third thing missing is any sense of a trajectory of change, including potential synergies, feedback loops etc. What could you achieve in ten years that would be impossible in three and how might dynamics within the system support that?
What follows, addresses the second point – trying to see how the various candidate priorities might fit within a coherent view of the existing system. It doesn’t address the third point, of trying to broadly plot changes over a timescale (except that some of that thinking may have implicitly influenced the choice of options).
The diagrams below represent an interim, rather than a finished, exposition. The lists of headings used are not comprehensive or exhaustive. But for now it should be sufficient to illustrate the process.
While this might seem a little complicated to start with, once you have a sense for how the strategic options have been derived, it should be fairly straightforward to follow. I have included the relevant diagrams at the appropriate points in the text, but since these are in JPEG format, you may not be able to see all of the detail, so all the slides as a single pdf are here:
The first diagram is a sort of crude cause and effect diagram whilst also outlining how different groups of people may be involved. This could be thought of as concentric rings, (as in the classic Dahlgren and Whitehead diagram, Ref 1) but I didn’t have room to display it in that way. The outermost layer (rose coloured) is the wider environment – things like anti-microbial resistance or the ageing population. Next are the social determinants of health, (shown in light brown), things like employment, transport and housing.
These then affect the more immediate factors influencing health and wellbeing, what I have called the ‘personal determinants of health’. These are equivalent to the individual lifestyle factors in the Dahlgren and Whitehead diagram but I think this is more than just ‘lifestyle’. It shows some of the ways in which the social determinants impact on individuals, such as stressors, living in damp conditions or financial situation. Some of these might be amenable to amelioration through individual action but the scope for action is strongly influenced by the circumstances people find themselves in.
Since priorities are often described in terms of groups of the population (grouped according to age or other demographics, vulnerability or state of health, by medical condition etc.) these differences are noted, (referenced in green), even though they have not be fitted into the cause-effect relationship .
The personal determinants, together with things like viruses, genes and the working of the human body are what cause ill health and wellbeing. Against this, in the yellow boxes are the various sorts of treatment and prevention. This is mainly intervention from the likes of health services, but it could include help from other services, voluntary organisations or indeed self-help, such as self-medication with over-the-counter drugs or simply resting to recuperate. Finally, the white boxes cover governance and supporting infrastructure (albeit without a comprehensive list of headings at this stage).
The next diagram uses the same components but strips out some of the detail (including the wider, environmental factors) and arranges it from left to right, with the more distant causes further towards the left.
In the next set of diagrams, the circles show where actions or interventions would be focussed. The straight line shapes show the areas of the system that would be affected (for instance, whether the actions would only affect a limited portion of the population or everyone).
The five ‘approaches’ (I think it would be a bit of a stretch to describe them even as embryonic strategies) are briefly described below. No doubt there are others that could be delineated in this way, but these are the things that immediately occurred to me and illustrate the general method. Varying the categories (such as highlighting different population segments, or dividing up the social determinants in other ways) could support the derivation of other, alternative strategic approaches.
The first approach takes ‘prevention’ as the theme. This envisages having the widest range of interventions of the five. It would include action on all of the social determinants of health. There would be action to help people improve their own health and wellbeing, such as through changing lifestyle. And there would be a rebalancing from treatment of illness to early intervention and prevention (such as by more health checks or screening for various conditions). This would affect all the ‘personal determinants of health’. It would apply to the whole population, though there might be more emphasis on some groups rather than others.
The second approach simply takes as its focus all of the social determinants of health. This would affect all groups of people and all personal determinants but would not directly affect treatments or interventions. The point of having this as an approach is that the social determinants are typically largely ignored (or not addressed as fully as they might be), perhaps because making such changes seems such a large and daunting prospect. So, having these as the sole focus means they could not be side-lined, put so far down the ‘to do’ list that they never get done, or implicitly slid onto the ‘too difficult’ pile.
The third approach is a stripped down version of the second, focussing only on the built and natural environment and the consequential impact on the relevant personal determinants of health. The rationale behind this approach would be that, as in the previous example, it would be less likely to receive sufficient attention if not highlighted as an area of focus but it could have substantial impact, and is more manageable than trying to tackle all the social determinants of health at once.
The fourth approach focuses on the community and the public. At the community level it is about things like community resilience and social capital – having strong bonds both within and between communities. At the more individual level it could include self-help, help from family and friends and peer support. It might also be broadened to include partnerships between the public and services, such as pursuing co-production. This could encompass prevention and early intervention by services.
The fifth, and final, approach would be to focus on children and young people. It could include action on all of the social determinants, all personal determinants as well as interventions by a range of public and voluntary services. The logic here is that people’s life chances are strongly influenced by their experience as children and particularly from conception to the first three years of life. It might be objected that the benefits of this approach would take many years to become apparent which might not be acceptable, particularly with shorter term political cycles. To counteract this, a proportionate universalist approach might be taken (as illustrated in the following figure), where there would continue to be attention to all age groups, but with a particular focus on younger ones.
As noted above, all of this is largely scratching the surface in terms of approaches but rather than spending more time on them, I will next go back to considering the trajectories of possible strategies and the interrelationships between various factors and how this may play out in systems terms. Hopefully this will allow the derivation of a wider range of broad, ‘realistic’ strategies.
Ref 1: Dahlgren, Göran; Whitehead, Margaret, Policies and strategies to promote social equity in health, Institute for Futures Studies, Stockholm, 1991