Whole System Change - a few ideas

 I suppose there are many ways to define what we mean by whole system change. It can mean different things to different people/organisations. I read a good example from Public Health Scotland, which defined a whole system approach in a way I understood. System change they suggest is:

“An ongoing, flexible approach by a broad-range of stakeholders to identify and understand current and emerging public health issues where by working together, we can deliver sustainable change and better lives for the people of Scotland.”

The piece I read went on to say something like:

“A whole system approach works when communities and stakeholders both understand the problem and support identification and testing of solutions. System change is a long-term endeavour, often delivered through incremental steps and collaboratively with many partners.”

If we take physical activity and its relationship with health and wellbeing as a product in relation to its product life cycle we have the stages of innovators (2.5%), early adopters (13.5%), early majority (34%), late majority (34%) and laggards (16%). The percentages are the suggested positioning of the population in relations to embracing change. I guess the percentages will vary according to the product involved and the market targeted.

I was in my local Halfords the other day getting a new battery for my car and I saw a chap putting together a bicycle. I said to him, “busy time of the year for bikes?” “It is,” he said “but I don’t know why we sell so many surely everyone must have one by now.”

So why are we as a nation of bike owners not clambering for improved cycling facilities?

Active Travel is a really important and growing concept. Local authorities are producing their active travel plans and the innovative ones and early adopters are putting their plans in place.

So maybe with Active travel and bicycles it really is the ‘cart before the horse.’ Or maybe it’s a lifestyle issue like a microwave oven. Everyone got one but few make full use of them. No joined up thinking here. A whole system change approach needed here?

Central government is intent on further reforms to the planning system and on the backside of Covid19 surely must come pressures on increased taxation both personal and importantly on public service providers.

Croydon Council I understand has declared bankruptcy. What will happen to non-statutory services? In Dorset both of our councils are currently looking at streamlining their leisure capital assets. ￡20million for a leisure centre site sold in a prime location to a property developer would be hard to resist.

If we end up with few facilities and fewer people able to afford the continued use of those that remain do we not need a whole change system approach to the wider delivery of accessible and affordable physical and mental health opportunities?

I have rambled on a bit because there is a lot of stuff going on now that needs addressing now because it can’t just be ignored. That said if we want to effect real change then someone has to step off the treadmill of uncertainty and unpick what we are doing and look at new effective ways of delivering what is actually needed and not what necessary is thought to be needed.

So is whole system change about what is it we want to change, who do we want to change it for, how are we going to make changes, with whom and by when?

I have highlighted what I see as the key words in the Public Health Scotland example of system change:

An ongoing, flexible approach by a broad-range of stakeholders to identify and understand current and emerging public health issues where by working together, we can deliver sustainable change and better lives for the people of Scotland.”

At a macro level I suppose the, we working together are potentially Sport England, Public Health England and Active Partnerships. There are I am sure others.

Clearly here in Dorset where we are a pilot in the whole system approach the, we working together is at a much more micro level (see strategy summary below).

I comment from a position of weakness because I have not had sight of the current evolving Sport England Strategy but I trust the links to active lifestyles and physical and mental wellbeing are embedded in the document. There has to be a strong link with the national plan to that which we are seeking to achieve in Dorset. For me it’s a fundamental part of what whole system change is about.

Where I was wrong when I gave you my reflections last week was that long term funding is not secure for partnerships going forward. Accepting that Active Partnerships will have as yet an undefined role to play in delivering the new Sport England strategy I suggest that what we need to be pressing for is the funding of more pilots like the one we have in Dorset.

Accepting that Sport England may have less resources going forward we need to question the effectiveness of programmes like the ‘extended workforce pilots. To date in Dorset we have seen little evidence of their effectiveness. Is there here an opportunity to redirect these resources? 

As Public Health Scotland said above, ‘System change is a long-term endeavour, often delivered through incremental steps and collaboratively with many partners.’ The work we do around physical activity and health and wellbeing as individual partnerships and collectively has started and accepting that it is a long term endeavour we need to be building on the learning to date and perhaps stop adopting other short terms programmes which seek to aid perceived short term issues. 

On a micro level there are a lot of talented people out there who are working within active partnerships who do much to deliver effective system change in the area of health and physical wellbeing. However when salaries in the Public Health sectors are ￡20k more a year don’t be surprised if they don’t hang around very long. 

So come post Covid19 we might well see for some time higher levels of unemployment, a depressed economy, less money in the public sector. We most likely will see a reduction in the take up of paid for physical activity and the provision of indoor public facilities. 

On the flip side investment in active travel, government recognition of the benefits of physical activity to the public health sector, a new Sport England Strategy and potential changes in planning policy gives us flesh opportunities to explore new ways to deliver physical active to an increasing number of people. We might even in time with a new approach get to some of the laggards. 

So where are we? If system change is a long term process delivered through incremental steps then we as an active partnership network need to adopt the position of innovators and early adopters of other innovations in the area of physical activity/health and wellbeing. 

To do this we need to build our evidence base, build our partnerships at both macro and micro levels, build and expand our workforce and increase skill levels in the areas of innovation and early adoptions. We need to be prepared to let, what is no longer current, go. 

We need to be bold and invest our reserves in our chosen areas of innovation and encourage others to do so. 

In the words of Henry Ford: “If you always do what you’ve always Done, You’ll always get what you’ve always got.”

I suppose real whole system change is not doing what we have always done and instead doing new things in new ways. Now that is a hard nut to crack.

Below is a summary of our recently published Physical Activity Strategy for Dorset Physical Activity Strategy | Active Dorset. Its picks up many of the points I have raised above about whole system change. It has taken nearly two years of hard work to get to this point. We would be pleased to share our learning.

It is fair to say that in Dorset the health train really has left the station, we have new passengers on board but have many more stops to make along the way and new passengers to collect before we reach our final destination. Where that destination is we wait to find out.

Physical Activity Strategy

Engaging all stakeholders across the County in a conversation about how we take a systems thinking approach to tackling inactivity in Dorset.

Summary

We are delighted to be working with our ICS partners, leading the development of a physical activity strategy for the county. This strategy will seek to engage all stakeholders across Dorset in a conversation about how we take a systems thinking approach to tackling inactivity in Dorset.

Dorset Physical Activity Strategy Update

Active Dorset and Public Health Dorset have been working closely to begin to plan the development of a physical activity strategy for the county. During January 2020 partners working across the Dorset ICS, in particular the two Health and Wellbeing Boards, agreed to develop a strategy to tackle inactivity in Dorset. The original timescales for this work were delayed due to the impact of coronavirus, as such we have used this time to reappraise our next steps and our proposed approach to developing the strategy with key partners.

The physical activity strategy will take the physical activity priorities identified in 'Our Dorset Looking Forward' and the two health and wellbeing strategies, engaging partners to identify what actions they can take to promote physical activity, so it becomes embedded as 'business as usual'.

Physical activity is identified as a key priority in both 'Our Dorset Looking Forward' and the BCP Health and Wellbeing Strategy. However there requires greater detail on how we work together to make changes across the Dorset system to affect behaviour, increasing activity levels, achieving a shift in culture so that business as usual empowers residents to be active.

Here is the timeline for development of Dorset's Physical Activity Strategy:

1. Engagement (Autumn 2020)

Identification of key stakeholders and engaging with them to secure their participation.

·        We will draw on our stakeholder mapping to engage with potential participants across systems and organisations to raise the profile of the approach we are developing, secure commitment to participating and potentially open the door to resources.

2. Discovery (Winter 2020/21)

Online workshops with key stakeholders to identify opportunities for system change drawing on their areas of expertise/influence.

·        Workshops will be based on 'discovery groups' convened to focus on each of the five areas identified by Sport England.

·        We will draw in key stakeholders who can provide both insights on their area of expertise/influence and commit to actions that will ensure the physical activity strategy delivers change. These groups will follow a system thinking process developed by PHD to:

·        Map and share understanding of what individual stakeholders do that shapes physical activity levels across Dorset

·        Identify the barriers and enablers of physical activity in the daily lives of people in Dorset

·        Identify actions for addressing the barriers to physical activity and harnessing the energy of existing enablers or 'levers' for increasing levels of physical activity in Dorset uncovered through the discovery phase.

3. Building the strategy (Spring 2021)

Drawing on better understanding of our challenges and opportunities to plan shared action for increasing physical activity.

·        Collating intelligence and insight from discovery phase and reflecting this back to stakeholders.

·        Prioritise system opportunities and actions

·        Planning implementation

·        Outlining a shared vision for physical activity across Dorset in 10 years' time. Our intention is to achieve a significant shift in culture through whole system change, this will be driven by a programme of smaller system changes monitored and tracked by a steering group.

4. Making it happen

Maintaining action and commitment

·        Creating a Dorset movement for movement. We will support participating stakeholders to form a steering group who will jointly own the strategy, maintain oversight, and hold one-another to account to implement the change prioritised in the strategy.

During strategy development thought needs to be given to what works best at the ICS 'Our Dorset' level, and where separate Local Authority level plans will best reflect and meet local needs.

Questions we are keen to ask during workshops with stakeholders include;

·        How can local plans be revitalised to improve policies and processes to promote or embed physical activity that support system wide change?

·        Where are the opportunities to embed physical activity in 'your bit' of the system?

·        How can we work at scale - all doing "our bit" rather than this being seen as someone else's problem?

·        What are the impacts of inactivity on the system within our 'business as usual'?

Active Dorset and Public Health Dorset are keen to work with partners to progress the planned next steps. We look forward to inviting you to workshops in 2021!