Some difficulties with clearly presenting a draft JHWS
I have done quite a lot of work over the past few months, refining my thoughts on what a decent Joint Health and Wellbeing Strategy (JHWS) might look like. That is largely because a new JHWS is being produced locally, and I have been trying to contribute to that process. I recently put in my response to an early draft of the strategy. On re-reading it, though, I didn’t think I’d made the arguments very effectively.
I think it’s worth reprinting part of my response, before I go on to consider what I might be doing wrong and what to do next. So this is how I described what the essence of a strategy might look like:
“The point about the framework (a summary of which is shown in the attached diagram) is to show what will produce change, over and above existing, ongoing operational activities. Significant change comes from a number of sources including resource reallocation (e.g. from physical to mental health) where this will produce greater ‘returns’ (in terms of people’s lives as well as financial); investment (such as in technology); and pathway redesign. These all need to operate within a complex system, whose non-linear processes can be exploited to produce larger than proportionate returns on inputs.
The essence of the strategic framework presented here is to move from the existing state to a new equilibrium, where prevention plays a much bigger role than at present. The idea is that it would cost no more (and possibly less) to have a bigger proportion of spending on prevention rather than treatment, with a resultant increase in overall health and wellbeing.
Prevention comes from four main sources: (1) services (screening, vaccination, early intervention etc.); (2) people’s lifestyle and behaviour (diet, physical activity, harm avoidance, social contact etc.); (3) the social determinants of health (incomes, employment, housing, environment, etc.); and (4) potentially powerful but hard to influence, are attitudes (such as reducing stigma around mental health), informal social contact etc. These four sources are not, of course, independent from each other and there are potentially beneficial interrelationships between them.
Interventions to address these four sources of prevention can broadly be divided into those which are targeted to particular individuals and those which are population-based. For instance, targeted support to homeless people, families with young children or people with mental health difficulties could include physical health checks, helping to change lifestyles, mitigation of the impact of social determinants (such as through debt counselling) and working with family and friends to promote wider understanding of the issues. At a population health level, it might be screening, lifestyle advice, encouraging payment of the living wage and campaigns to reduce stigma and promote social connectedness.
The essence of the strategy, then, is to work on the four sources of prevention, exploiting the interrelationships between them, so as to gradually reduce demand for services such as treatment for physical or mental ill health. The savings from that reduced demand can then be ploughed back into prevention and early intervention in a virtuous circle. Over the long term, this is an attempt to ‘reset’ the system. Additional resource is required to get over the hump from the present situation to the future equilibrium, but the future state will be more effective and efficient in terms of health and wellbeing.
A reduction in health inequalities is achieved by (1) targeting those in most need, (2) a proportionate universalist approach in services and population health management and (3) reducing structural inequalities by redesigning social determinants.
While that forms a central dynamic, there are other sources of improvement to be exploited such as judicious investment in technology and system and pathway redesign (to try and provide whole-person, whole-journey, whole-system care). Work on children’s mental health should have long lasting results, into adulthood.”
While this does say some of what I am trying to get across, it is still quite clumsy: rather too much of a catalogue or structuring of factors, rather than really focussing on the key underlying dynamic. But that’s not the only issue.
I think there are essentially three problems:
- coming up with the ideas for a viable and effective strategy,
- presenting that in a reasonably simple way that people can understand,
- presenting it in a persuasive way that might change people’s minds.
Coming up with ideas for a viable and effective strategy is something that should be done by all the relevant stakeholders. All I am trying to do is show what might be possible. This can be progressed by working iteratively between the detail and the big picture.
Presenting it in a simple way requires both narrative and illustration. I tend to make a lot of use of diagrams. I think one problem is that I have spent a lot of time trying to include everything in one diagram. That is conceptually difficult (you are mixing many dimensions in one space) and requires considerable clarity and focus. So it might be better to work more systematically through some of the detail and the different perspectives first.
Amongst the different perspectives (or ‘dimensions’) you might wish to show are:
- The components of the health and wellbeing system (social determinants, people, treatment, outcomes etc.)
- Scope for major change – what are the strategic issues
- Some sort of input-output or logic model
- A systems dynamics model that recognises the various feedback loops
- Some sort of chronological outline plan – what you are going to do when and what it should achieve.
These each present a different view of the strategy, but none of them on their own are enough to tell the whole story.
I have versions of all of those, but it is actually very time consuming to produce something decent. So the next stage is to go back and produce a decent version of the perspectives. I will try and do that for a strategy as a whole and perhaps some element of it such as mental health or physical activity. Perhaps when I have a greater degree of clarity, I will be able to find a way to combine it all into a simpler, more persuasive diagram.
A persuasive presentation is only one part of influencing and producing change, though. And that’s a whole other story.