[A shorter version of this blog appears on Knowledge Hub.]

I think joint health and wellbeing strategies are great.  Potentially.  They could do so much.  But I’ve yet to find examples where they do.  At their best, they could be a focus for collaboration across health, local government, the voluntary and other sectors to really make a difference to local health and wellbeing.  Too often, it seems to be a token effort, or it’s given up as being too hard.

And that’s the problem.  It is hard.  It’s not hard to put some words on paper that sound vaguely sensible but to get a strategy that works requires creativity, innovation and not a little inspiration.  A start, though, is to ensure it does all the things a strategy should do.

Of course it’s not the piece of paper that’s important, but how it can act as a focus for well thought through, evidence based, collective action.  But the piece of paper is where you write down what that ought to be, and if you get that wrong you’re unlikely to get results.

I think a strategy should give you a sense of where you’re trying to get to and the path you will follow to get there.  Hardly controversial.  And yet many Joint Health and Wellbeing Strategies (JHWS’s)  don’t seem to do that (if you know of any that do, I’d love to hear from you).  The ones I’ve read so far seem to be quite short, set out some sort of vision, a list of priorities, some outcomes and occasionally something about who is to do what and who will be accountable.

So what do I think should be in a JHWS?  My simplified view of a strategy is that it should: (1) say where you’re trying to get to; (2) look at the current context and the likely future environment; (3) provide some sort of analysis; (4) offer up options; (5) suggest a path to reaching the objectives; and (6) say how you’re going to implement it.  So what might this look like in a JHWS?

The strategy needs to highlight and focus on what’s new and where there are cross-sector and cross-service issues.  However it also needs to be comprehensive, at least at an outline level, encompassing all health and social care provision, social determinants of health, prevention and the role of the public in health and wellbeing.

So what, broadly, should each of the sections cover?

(1) Aims. This should take a long term view, perhaps with 3, 5 and 10 year time horizons (and maybe longer).  Most strategies seem to tackle objectives and outcomes pretty well so I won’t say more about them here.  I think there’s a lot more to say about ‘priorities’, what they are and why you have them, but that needs a separate discussion another time.  The ultimate objective is likely to include improving the overall level of, and reducing inequalities, in health and wellbeing (including positive mental health).  That’s likely to be measured by increasing healthy life expectancy (i.e. years of positive health and wellbeing) while reducing ‘health’ inequalities.

(2) Current context and future environment.  The detail of the current context should already be in the JSNA.  What the strategy needs to do is pick out the most important aspects and interrelationships between them.  It also needs to summarise the key environmental factors.  That’s likely to include the impending funding crisis. The ageing population will be in there, together with trends on conditions such as cancers, diabetes, dementia, and cardiovascular health.  There will be something on likely changes in determinants of health such as obesity, exercise and activity, unhealthy behaviours (such as tobacco and alcohol) and social capital.  There are likely to be big changes in technology, medical and other, over the next ten years or so, so the strategy should say something about that.  And there will be very local factors to do with environment, demography and the economy.  There will also need to be something on current plans for provision of health and social care and other services (e.g. the further cuts to come to local government, what are the projected bed numbers and capacity of the local acute trust).  Generally, then, the question is, what’s the terrain your journey will take you over, and have you any influence to change it?

(3)  Analysis.  The analysis needs to look at how, given that environment, the objectives can be met.  The argument might go something like this.  Health and the council need to improve quality and efficiency individually and together, but they’re already engaged on that (through their improvement and integration programmes) so we’ll just keep a watching brief on those areas (and we’re probably dealing with integration separately anyway).  There will be lots of other things already going on, e.g. some aspects of prevention work, which should be noted and kept as part of the overall picture but don’t necessarily need more time and attention here.  The question is, what needs to be done differently.  In many cases I would think that would include more on prevention and involving the public as an equal partner in managing and improving their health.  The analysis will probably include something about what incremental improvements can be made with what resources (how much do we need to give Public Health for the improvement work).

There needs to be some assessment of what results are likely from different combinations of actions.  Some of that information may already be available, such as the cost-effectiveness of stop-smoking campaigns.  For other aspects, particularly if you get some momentum going it may be very difficult to predict accurately what outcome you can get from a given input.  It should be possible to make some assessments though, even if with just very broad ranges.  For instance, based on nationally available evidence, if we managed to reduce obesity from 25% to 15% it would save so many lives, or quality adjusted life years (QALYs) (through its impact on a series of specified conditions).  Spending A on this aspect of social care could reduce delayed discharges by B.  Reducing loneliness by X will have this affect on mental health and save Z ‘Qualys’.  It might only be ‘back of a fag packet’ but it could help focus attention in the right places.

However, that is all approximate and it will often be difficult to predict exactly what changes there might be.  It wouldn’t, then, make much sense to set very specific targets (such as ‘we will reduce obesity by 2.7%).

The interesting bit of the analysis, though, is how you put the pieces together in interesting and effective ways, rather than just commissioning a series of separate silo services.  It could be finding leverage, reaching a critical mass of interventions, or building momentum and positive feedback loops.

There may be opportunities for leverage, where a small input could produce a big change.  For instance, if you improve mental health, you also improve physical health – there is a knock on effect.  Work with ‘troubled families’ can have a big impact on a wide range of outcomes.  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.

It may be that a concerted series of actions can achieve more than the sum of their parts.  A concerted effort to get the district active  – involving, say, a communications campaign, changing the environment (e.g. making it easier to walk or cycle) and incentives from employers –  might actually achieve something where individual initiatives have minimal effect.  However that 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.  And the starting point for that is to have it in the strategy.

If could be finding positive feedback loops which generate non-linear results.  In other words, you make some changes but they feed on each other, like a snowball gathering snow as it rolls downhill.  For instance, as people become active they build confidence, they start to take more control of their health and eat better.  When people see their friends and relatives losing weight they think they might have a go.  As people become healthier, the costs of treatment go down, and that money can be used for other initiatives.

(4)  Options.  There are likely to be more things that could be done than there will be resources for so there needs to be some choice to allow decisions which take account of what is most cost effective and variations values and in how risky you want to be.  The status quo should be one of the options – not that many people are likely to defend it explicitly, but it’s the most likely to happen if there isn’t a coalition of support for something else.

(5) The path towards a solution.   So what does that path look like?  It can’t be a blueprint, because the world is too complex and messy for that.  So there needs to be room to add detail and to modify the approach depending on experience.  But it needs to be more than generalities and banalities.  Certainly there needs to be enough to influence commissioning plans.  It should include an indication of the resource to be applied to different aspects of it.  So, for example, it should indicate the relative roles of prevention as against treating illness and social problems.  Within prevention there might be a programme on increasing activity amongst the public.  Elements of that would include a public health campaign, making it easier to walk and cycle safely (well lit paths to schools and shops, cycle lanes, places to leave cycles securely), peer support for elderly people’s physical reablement, routine provision of advice through GP surgeries etc.  The precise detail may not be there, but there needs to be enough to give people confidence that something is actually going to happen.

(6) Implementation.  Implementation includes allocation of accountability to panels, sub-committees and individuals, across the council, CCG, voluntary sector and others.  It also needs to allow for a process of continuous sharing, learning and revision.  So while there is a role for project and programme management, there also needs to be a process of continuous sharing, learning and revision.  That should include learning from each other but also learning from experience over time.  You need to get the people from housing, the GP surgery, police, voluntary sector etc. together to flesh out the ideas in the strategy but also to come up with new ideas.  Some things won’t work and you may need to change direction.  So that all needs to feed back into refreshes of the strategy.  It needs to be an iterative process, up and down.

The strategy, in other words, is a tool.  The real work is in the discussion of what needs and can be done and in the collaboration between sectors.  The strategy is where you record what’s been agreed.

I don’t think the JHWS needs to be kept brief (as many are).  It should be as long as it needs to be, with further supporting evidence available.  Certainly there should be a much shorter, easily accessible summary as well.  There needs to be something people will actually read and the essence of which they can keep in their heads.  But that has to be underpinned by a more substantial piece of work.

All of that isn’t easy.  It takes time, effort and resources to achieve.  And who has got those to spare at the moment?  But how else can we have any chance of dealing with the massive cuts yet to come in council spending or the £30bn NHS black hole, never mind helping people be healthier and happier?