Gloucestershire Health and Wellbeing Board - Gloucestershire County ...

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5.0 What have been the additional benefits of this work? 5.1 By definition this approach will not offer a 'quick-fix'. H
Gloucestershire Health and Wellbeing Board Report Title

Systems Leadership Programme Update

Item for Item for information and decision decision or information? Sponsor

Linda Uren and Mary Hutton

Author

David Bolger and Sue Weaver

Organisation Gloucestershire County Council Key Issues: • •

National support for the Systems Leadership Programme (SLP) formally ceased at the end of March 2014 This report summarises the benefits and learning from the project to date and proposes options for supporting the further development of systems leadership capacity and approaches in Gloucestershire, and for building on the learning and early impacts around intergenerational obesity.

Recommendations to Board: The Board is asked to note the contents of this update and to considers and comment on the proposed next steps, in particular the proposal for the continued function of the SLP Project Board as a resource available to the Gloucestershire Health and Wellbeing Strategy Implementation Group (SIG) to provide peer support and challenge to help apply systems approaches to other areas of the Board’s business.

Financial/Resource Implications: None directly arising from this update

Systems Leadership Programme Update ___________________________________________________________________ 1.0 Purpose 1.1 To update the Board on the local implementation of the Systems Leadership Programme (SLP) including the learning and tangible benefits to date, and options for taking forward this learning to other aspects of the Board’s strategy.

2.0 Background 2.1 The Board will recall bidding successfully for support for a SLP project, focusing on intergenerational obesity, our locally identified ‘wicked issue’. These projects have been funded by national sponsors including Public Health England, the National Skills Academy and the Local Government Association. National support for the project formally ceased at the end of March 2014. 2.2 The aim of the national programme was to develop leadership capacity at a local level by applying systems approaches to address so called ‘wicked issues’. 2.3 Wicked issues involve complex, messy and often intractable problems that can rarely be totally eliminated. The causes of wicked issues are complex, ambiguous and interconnected, not simple or linear. Therefore there are no single, straightforward solution and multiple, partial solutions are called for. 2.4 Leadership within such ‘systems’ requires attitudes, skills and approaches that go beyond traditional mechanistic ideas of management and change. Systems approaches involve: • Developing an understanding of the system, particularly the way component parts relate • Gaining an appreciation of the different perspectives of key players within the system, starting with the perspectives of the intended ‘recipients’ of services and interventions • Making new connections between different parts of the system; it is the quality of these connections that contribute to transformational change. This requires the development of different relationships between commissioners or policy makers and citizens, communities and providers. 2.5 Developing such leadership capacity is best approached through ‘action learning’; working collaboratively across the system on a ‘live issue’ and drawing on the multiple perspectives of participants. The national programme was designed according to these principles.

3.0 How did we approach this project in Gloucestershire? 3.1 The two high level objectives for the local SLP project were to: • Develop systems leadership capacity within the Gloucestershire Health and Wellbeing Board (GHWB) and across the wider partnership • Use systems principles to review our local approach to reducing intergenerational obesity.

3.2 We set up a small project board representing different parts of the local ‘obesity system’ (see appendix 1 for membership), which met monthly for the duration of the project. 3.3 The project board identified three local communities to focus on, all with high levels of child obesity; these were Matson and Podsmead in Gloucester and Oakdale, a new development in Lydney. 3.4 The SLP Board agreed a set of working principles for the project aligned to the following key principles of ‘Fit for the Future’, the Health and Wellbeing Strategy for Gloucestershire: • • •

Supporting communities to take an active role in improving health Encouraging people to adopt healthy lifestyles to stop problems from developing Supporting individuals or communities where life expectancy is lower than the county average or where quality of life is poor.

3.5 The project board agreed the following specific objectives for the core timescale of September 2013 to March 2014, with the intention of working at three different levels in the system: Community Level • To identify effective mechanisms for promoting and enabling behaviour change in individuals, families and communities in relation to eating and physical activity. Operational Level • To develop a better understanding of ‘what and who’ comprises the local obesity and healthy living ‘system’, and the different perspectives that exist within the system • To promote systems leadership approaches and develop capacity within the system for the future • To develop a locally owned and shared plan for promoting and enabling healthier lifestyle behaviours. Strategic Level • To use the obesity project to experiment with systems leadership approaches with a view to applying the learning to other strategic priorities • To develop systems leadership capacity across the GHWB’s partner agencies and deploy these approaches across the Board’s strategic remit. 3.6 The process taken is given in Figure 1 below. In the spirit of ‘following where the work takes you’ the group did not develop formal action plan but set out to undertake enquiries as to what is needed before we can move on to how we better coordinate approaches and interventions.

Figure 1: SLP Process Collate existing knowledge /data around obesity, including evidence of what works

Map the local ‘obesity system’ – key activity, services, assets and partners

Identify opportunities for partner and community engagement

Collaborate with community to develop solutions to identified issues and priorities

Establish better connections between partners to join up and embed obesity prevention across services and policies

4.0 What has been the learning from this project? 4.1 At the start of the project the SLP Board undertook a rapid review of the published evidence for obesity prevention. This found that, while a number of single interventions have demonstrated an impact on the behaviour of individuals, there is a lack of evidence of which ‘package’ of community-wide measures, could reduce obesity at a population level. 4.2 The limited published evidence on cost-effectiveness of obesity prevention interventions suggests that policy and environmental approaches tend to show greater cost-effectiveness than targeted health promotion or clinical interventions because they benefit the entire population. 4.3 While no country in the world has successfully reversed the ‘obesity epidemic’ early evidence from the most advanced community-wide prevention programmes have shown some impact on the prevalence of child obesity in participating towns and cities. Then following elements are considered central to the success of these programmes: • • •

• •



Strong political commitment Long term commitment and investment over at least five years Local dedicated project managers to oversee coordination, networking and communication to ensure a large and sustainable mobilisation of local stakeholders Sustained community and stakeholder engagement A capacity building approach starting with action in schools as the first step in raising awareness, followed by mobilisation within the community, with families being the key target A scientific expert committee to oversee evaluation.

4.4 The most powerful learning from this project was achieved through direct engagement with residents of the three communities by members of the SLP project board, and latterly GHWB. Key learning points are summarised below: Communities are capable and resourceful The communities we worked with are capable and engaged. We found high aspirations around healthy living, including better nutrition and active lifestyles, and many innovative examples of health improvement interventions being delivered with little or no public sector involvement or funding. This often hinged on the energy, commitment and resourcefulness of one or more individuals within a community. It’s not about obesity; finding out, and framing the issue in a way that resonates with communities is the key The issue of obesity was not on the agenda of the communities we worked with but, by listening to what was important to local residents, and framing the issue within the wider context of health and wellbeing, each community identified ambitions and activities that could contribute directly to obesity prevention. Ownership is the only way to deliver sustained change We noted a feeling of powerlessness in some communities, with too much power seeming to reside in distant agencies that fail to take into account local views. Top-down behaviours do not resonate with the way local communities want to be engaged. Ownership is the only way to deliver sustained change and communities clearly articulated that they do not want our ‘solutions’ to improving health and wellbeing, that they want to be involved in the development and, where appropriate, delivery of interventions, or simply some support to do things ‘their way’. ‘Come and ask us about what we need – and what we can do for ourselves – before you make decisions’ Communities cited a number of examples of well-intentioned interventions, often involving significant resource, being delivered without their involvement. We heard examples of unintended consequences including: missed opportunities, poor participation / wasted resource, and in some instances the intervention itself posed a barrier to healthy living. It doesn’t have to cost a lot The support we were asked for was rarely financial, and where it did involve some initial funding, it was only nominal amounts. Requests for support have included listening and assisting, advocacy, practical support around ‘how to’ deliver interventions (e.g. set up a Food Bank or a Community Food Cooperative), help to make the right connections or help to ‘unblock’ specific barriers within the system. They asked us to consider different ways of commission some of our services that enable them to be involved at all stages of development and implementation, for example, opportunities to bid for small grants to deliver community-led interventions.

Follow where the work takes you By definition, this type of working is continuously evolving and plans will change regularly, and must be allowed to progress at their own pace. This means that the traditional approach of defining objectives in measurable terms and developing a neat action plan to deliver them, does not apply. A more iterative approach is needed, incorporating regular opportunities to reflect and review, before agreeing next steps. Solutions need to developed on a very local level There is no ‘one size fits all’ solution, and no single organisation is able to affect the range of solutions necessary to address a wicked issue. Furthermore, each community has its own unique issues, priorities, assets, culture and energy; and community-led solutions will need to be developed at very local level. Co-production takes time It takes time to develop relationships and build trust, and this requires a longterm commitment from stakeholders or project leads to spend time on the ground. For this reason, and the fact that the solutions that arise are different for each community, this sort of approach lends itself to projects that are limited to small geographical areas or communities of interest.

5.0 What have been the additional benefits of this work? 5.1 By definition this approach will not offer a ‘quick-fix’. However, the project has achieved the following early tangible benefits Community Level Direct engagement with residents has helped to progress a series of activities including: • Helping to remove local barriers to walking and cycling (Oakdale), through liaising with the developer to expedite the completion of a footpath and lighting • Brokering connections between local communities and existing services with a view to ‘helping communities help themselves’, for example, Oakdale residents have elicited the support of the Gloucestershire Stop Smoking Service to develop a Knit and Quit stop smoking support group. Podsmead residents are looking to run their own weight management peer support group, and cooking sessions • Supporting Podsmead residents to realise their ambition to develop a Community Food Cooperative to plug a gap in access to fresh ingredients • Working with Matson community to explore/progress their interest in hosting the local library within the community centre. Operational Level For the wider obesity system, the Project has developed ways of working proactively and confidently with communities, and with partners across the system, for example: • Relationships and a level of trust have been built between the SLP Board and a number of local community groups. This can be used as a resource for ongoing engagement and co-production of interventions • A workshop was facilitated between providers of services across the adult weight management care pathway. This resulted in better connections

between and opportunities for collaborative working services, more effective signposting to community facilities / support at no additional cost • Connections have been made between other work streams aiming to deliver transformational change, including Families First and Turning Point delivery. The Domestic Abuse and Sexual Violence Partnership has sought advice from the SLP Board on how to apply systems approaches to this agenda • In March a systems leadership workshop was held to promote systems leadership approaches and develop capacity among GCC commissioners, with a further workshop to take place later in the year, and future opportunities to share these approaches as part of the organisational development agenda being discussed with GCC and CCG leads. Strategic Level The majority of members of GHWB attended an event in January, hosted at the Redwell Community Centre in Matson. This highlighted some of the learning from the SLP, with the lively cooperation of representatives from all three communities. Members of the Board were impressed by the level of energy and resourcefulness within the communities, and the opportunities to foster different relationships with communities in developing and delivering future services. There is scope to apply systems thinking more broadly across a range of lifestyle-related issues, taking a person-centred approach rather than focusing on a single lifestyle issue. In addition there is clear potential to apply these approaches across other areas of the Board’s business, for example: • Development of the domestic abuse strategy • Implementation of the Better Care Fund • Development of self-care and self-management agendas • Living Well. 6.0 Next steps 6.1 There remains the potential for the GHWB to embrace these approaches more broadly and also to build on the learning and outcomes around obesity to inform future commissioning. The following ‘next steps’ are proposed in order to maintain the momentum of the project against its original objectives: Objective 1: Developing systems leadership capacity within GHWB and wider partnership 6.2 A number of further opportunities to receive support around systems leadership are likely to be offered by national sponsors. These include the cross-sector ‘Leadership for Change Programme’, aimed at leaders and emerging leaders in adult and children’s care, and health. This provides an opportunity to access training and facilitation to help to address another locally-identified commissioning challenge. The Gloucestershire Clinical Commissioning Group (GCCG) is preparing a bid to take part in this Programme. 6.3 National SLP enablers have fed back to us that Gloucestershire is well regarded nationally as a result of its level of engagement with the current programme, and that there is a further opportunity for us to submit a bid for further support to extend and build on the learning and outcomes from this project.

6.4 Members of the current SLP Board propose that it could become a more generic (not obesity-specific) resource for the system, providing peer support and challenge to help apply systems approaches to other areas of the GHWBs business. 6.5 A further facilitated development session will be made available to the Board later in the year to inform and enhance the Board’s own working style. Objective 2: Using systems principles to review our local approach to reducing intergenerational obesity 6.6 It is proposed that the obesity prevention work is progressed under the wider umbrella of ‘transforming health behaviours’. This is a GCC-led project that aims to review how we enable and support communities to help themselves to adopt healthier lifestyles including eating well, being physically active, drinking alcohol within safe limits, stopping smoking and looking after emotional health and wellbeing (the key lifestyle areas that are known to have the greatest population-level impact on healthy life expectancy, and on health inequalities). 6.7 This work will include a review of existing lifestyles services and will inform commissioning decisions across these areas. The scope and governance for this project will be agreed during the first quarter of 2014-15 but will include engaging more widely across obesity and other lifestyles ‘systems’. Among the issues and questions raised during this project, this work will explore possible commissioning approaches to delivering interventions and services at scale, while supporting the provision of relevant community-led solutions at very local level. 6.8 Meanwhile, we will maintain our relationship with the three communities we have worked with, and our commitment to supporting them to progress the activities highlighted above.

7.0 Summary and recommendations 7.1 This project has set the direction for change and has enabled us to start developing capacity and strategies to embed systems approaches across other areas of the Board’s remit. 7.2 The recommendation to the board is that it considers and comments on the proposed next steps, in particular the proposal around the future function of the SLP Project Board.

Appendix 1: Systems Leadership Project Board Membership Name

Role

Organisation

Email

Councillor Dorcas Binns

Cabinet Lead for Public Health and Communities

GCC

[email protected]

Councillor Jennie Dallimore

Deputy Leader of Gloucester City Council & Cabinet Member for Communities and Neighbourhoods

Gloucester City Council

[email protected]

Alice Walsh

Interim Director of Public Health

GCC

[email protected]

Mark Patterson

Acting Head of Health and Wellbeing

Public Health England

[email protected]

Dr Hein Le Roux

GP and CCG Board Member

Gloucestershire CCG

[email protected]

Diana Billingham

Public Health Manager

GCC

[email protected] v.uk

Sue Thompson

Commissioning Officer

GCC

Susan.THOMPSON@gloucestershire. gov.uk

Louise Matthews

Commissioning Officer

GCC

[email protected] v.uk

Justine Rawlings

Associate Director Clinical Programmes

Gloucestershire CCG

[email protected]

Tess Tremlett

Community Engagement Manager

Forest of Dean District Council

[email protected]

Philip Williams

Lead Commissioner Community Infrastructure

GCC

[email protected] k

Sue Weaver

Public Health Manager

GCC

[email protected]

Helen Flitton

Project Officer

GCC

[email protected]