School of Medicine & Health

The Wicked Issue of Health The Wicked Issue of Health InequalitiesInequalities

Professor David HunterProfessor David Hunter

School of Medicine & Health

For every complex problem, there is an answer that is clear, simple and wrong

H L Mencken (1880-1956)

School of Medicine & Health

Failure of Policies and Systems: Failure of Policies and Systems: Why?Why?

Lack of political will – vested interests in Lack of political will – vested interests in maintaining status quo maintaining status quo

Policy incoherence – push and pull in different Policy incoherence – push and pull in different directionsdirections

Systems and structures not ‘fit for purpose’ Systems and structures not ‘fit for purpose’

Bias towards downstream interventions – Bias towards downstream interventions – ‘lifestyle drift’ ‘lifestyle drift’

Lack of capability and capacity to tackle to Lack of capability and capacity to tackle to complex wicked issuescomplex wicked issues

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Paradigm ShiftParadigm Shift

Acknowledge existence of ‘wicked issues’Acknowledge existence of ‘wicked issues’

Value of a systems approachValue of a systems approach

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Defining Features of Wicked Defining Features of Wicked Issues (1)Issues (1)

Difficult to define – no definite formulationDifficult to define – no definite formulation

Continually evolve and mutateContinually evolve and mutate

Multiple causesMultiple causes

InterdependentInterdependent

Cross-governmentalCross-governmental

Conflicting goalsConflicting goals

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Defining Features of Wicked Defining Features of Wicked Issues (2)Issues (2)

Solutions may have unforeseen Solutions may have unforeseen consequencesconsequences

UnstableUnstable

Socially complexSocially complex

Solutions are better or worse, not right or Solutions are better or worse, not right or wrongwrong

Context is all-importantContext is all-important

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Complex Adaptive SystemComplex Adaptive System

A collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions changes the context for other agents.

Plsek and Greenhalgh (2001), BMJ

School of Medicine & Health

Contrasting Approaches

Rational, managerial approach Complex adaptive system

• Organisation is a machine • Organisation is an organism adapting to its environment

• Plan and control • Learn and adapt

• Ideas produces by specialists/experts • Ideas can emerge from anyone

• Implementation is well planned and can be a replication of structures and processes that have worked elsewhere

• Can be informed by what has worked elsewhere but must be adapted to local context

• Primarily an issue of evidence dissemination

• Primarily an issue of sharing knowledge through social relationships and adapting ideas to local settings

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The Complex Adaptive LeaderThe Complex Adaptive Leader

Manages context and relationshipsManages context and relationshipsCreates conditions that favour emergence and Creates conditions that favour emergence and self-organisationself-organisationLet’s go of ‘figuring it all out’Let’s go of ‘figuring it all out’Works with simple rules – good enough Works with simple rules – good enough information and minimum specificationsinformation and minimum specificationsLaunches many diverse experiments, reflects on Launches many diverse experiments, reflects on what is happening, instead of trying to figure out what is happening, instead of trying to figure out the ‘one best way’the ‘one best way’Works with natural attractors and flows rather Works with natural attractors and flows rather than always relying on formal structures than always relying on formal structures

School of Medicine & Health

Wicked Issues and Performance Wicked Issues and Performance Assessment: The case of health Assessment: The case of health

inequalitiesinequalities

A comparative study of England, Scotland A comparative study of England, Scotland and Walesand Wales

Research teams from Durham, Aberdeen Research teams from Durham, Aberdeen and Cardiff universitiesand Cardiff universities

School of Medicine & Health

Constructing Health InequalityConstructing Health InequalityHealth inequalities were widely seen in all Health inequalities were widely seen in all countries as caused by deprivationcountries as caused by deprivation

Focus in England on ‘quick wins’ driven by Focus in England on ‘quick wins’ driven by performance assessment and availability of performance assessment and availability of models for secondary preventionmodels for secondary prevention

Target-driven culture absent from Scotland and Target-driven culture absent from Scotland and WalesWales

In Scotland, focus on joined-up government In Scotland, focus on joined-up government approach to health inequalitiesapproach to health inequalities

In Wales, no driver for focus on health In Wales, no driver for focus on health inequalitiesinequalities

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Is Scotland Showing the Way Is Scotland Showing the Way Forward?Forward?

Recognition of the need

To continue breaking down organisational barriers and encourage working across departmental silos in order to achieve overarching objectives.

Taking Stock review (2006)

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The Scottish ExecutiveThe Scottish Executive

…has emphasised the maintenance of a unified corporate identity. This has also been promulgated through the matching of ministers to topics that cross departments, rather than identifying ministers clearly with specific departments.

IPPR, Innovations in Government (2007)