Tools for the day job: Adding quality and systems to public health practice

In 1988 Sir Donald Acheson, then Chief Medical Officer, defined public health as ‘the art and science of preventing disease, prolonging life and promoting health through the organised efforts of society.’

Much of that still rings true for me. On an average day, the challenges facing any Director of Public Health, or senior public health professional are varied across these: part commissioner, part scientific adviser, part ferret (snaffling around the population data to identify where we are missing people, or where population issues are coming up that we need to address). 

But while some aspects of the job may not have changed, the whole nature of what we’re trying to do has, and the context we are trying to do it in. No single agency can improve and protect the health of the population any more. It is, truly, everybody’s job – and that brings both opportunity and challenge. Increasingly, the tasks feel like trying to conduct an orchestra, in tandem with nine other conductors all wanting slightly different rhythm, harmony and cadence. Oh, and there seem to be several melodies going on, most of which aren’t fully understood by the other players.

Influencing people across different agencies and systems, and trying to provide technical input on a range of issues from how to make sure new planning and housing developments work for rather than against health, to technical aspects of health protection. There is, truly, never a dull moment.

But there is also the need to commission a portfolio of services against reducing budgets thanks to cuts which, I think increasingly, people are saying were mistaken.  I believe passionately that the services I commission – sexual health, drugs and alcohol treatment, health improvement, smoking cessation, school nursing, health visiting and others – are important, and must be the very best we can make them with the finances available.

While it’s easy to get sucked into the maelstrom of governance and organisational change that has come with Sustainability and Transformation Plans recently, we risk forgetting the fundamental point, which is the enduring task of working for the public’s health. I increasingly call these ‘The Three O’s’:

• orchestrating a diverse range of players to work for citizens
• optimal operation of systems and services
• outcomes for people.

To be honest, I think I’m stating them in reverse order of logical importance, but actual order of what I end up doing most days. And while my public health training has stood me in good stead, it hasn’t given me everything I need to do this job. I have a range of technical skills I still use regularly such as intelligence gathering, interpreting evidence, methodically identifying what the needed action and outcome is in a particular situation with a range of partners. But I need other skills and insights too, like the three Os.

I also believe senior public health professionals need to fall back on another strong streak of habit accustomed to us: we take and use insights from other fields and blend them into our work. Epidemiology, service audit, psychology of behaviour change and other insights have been adopted and adapted by public health professionals. Indeed, you may have seen me write and advocate frequently in other places for the value of behavioural sciences in public health.

However, there are another three sets of insights I passionately believe public health professionals are seeing the benefit of, which I personally have seen significant benefit from. These are:

• systems approaches
• leadership in systems
• quality improvement.

I believe that the crucial task for senior public health professionals now is to influence systems, and that means we need to understand both systems approaches, and leadership in systems. Public health has come somewhat late to these insights, but as a recent Health Foundation webinar and some recent publications have shown, we are busy making up for that. 

One essential ingredient in understanding systems is knowing how to lead in and across them. This is a different game than it was, I believe, when I started out in my career. Bringing together a range of diverse players sounding different notes to a shared harmony is more about orchestration than managerial power. But make no mistake, there are issues of influence and power to be addressed in how one does this.

Finally, there is the need to keep squeezing more demand and capacity out of less money. The slicing techniques we may have used in the past don’t work – and service redesign requires a greater variety of tools than many of us learned. This is where quality improvement and efficiency sciences come into their own.

These new things are crucial to me everyday, but my training didn’t really prepare me for this world. While my career has since prepared me to an extent, it’s always good to identify growth opportunities.

I have been fortunate to be part of something which helped with these. I have been privileged to be part of the Health Foundation’s Generation Q programme as a Fellow. Very few public health professionals have gone through this fantastic programme, and I would wholeheartedly encourage you to apply for it, if you’ve not already done so. (The deadline is 10 January 2018.)

The programme goes to the heart of some of the issues I face every day: getting insights from quality improvement to drive value in commissioning, understanding how to influence, and identifying how to make improvements from system level to service level. Most crucially, though, through this programme, I am gaining a greater understanding of who I am and how I work, and what that means for how I lead with others. If you engage with it, the reflective and interactive nature of this programme cannot but help you get your bearings for a changed world and system.

If any of what I have said resonates, do check out Generation Q.

Jim McManus (@jimmcmanusph) is Director of Public Health for Hertfordshire, Membership Secretary of the Association of Directors of Public Health, and a Generation Q Fellow