Introduction

This study is an investigation of the degree to which systems thinking is an ‘absent competence’ or a ‘constrained capability’ amongst those involved in leading partnership working for wellbeing and health in an English city.

It intends to contribute to academic writing using the discipline of Systems in the domains of Public Health, Partnership and Leadership. There have been recent changes in understanding health that have led to it being framed through the concept of ‘wicked issue’ (Rittel & Webber 1973) with associated suggestions about new ways of conceptualising partnership working. Whilst the body of literature I have reviewed argues for a ‘new paradigm’ or ‘new way’ of working based on ideas from Systems (Hunter 2009; World Health Organisation, Regional Office for Europe 2011), it rarely discusses how this systemic change can be brought about. In fact, the only change actions identified relate to the need for development of leaders, including the need for ‘systems thinking’ skills (e.g. Hunter 2009; Alban-Metcalfe & Alimo-Metcalfe 2010).

I argue that research to date has failed to value the natural systems thinking capability of leaders and overlooked the constraints placed on systems practice by the setting in which they carry out their work. The study intends to provide empirical evidence to support this claim thus broadening the range of possibilities for future research and practice improvements.

The study is of relevance to those seeking to improve the domain of practice concerned with working in partnership to improve wellbeing and health (and reduce inequalities) at an English local authority level. The research is timely to the participating city and also of interest to other English local authorities as new ‘shadow’ Health and Wellbeing Boards are being established in accordance with proposed statutory requirements in the Health and Social Care Bill (Lansley & Howe 2011).

The participating city is starting a year-long partnership development action research project based on Appreciative Inquiry (Ludema et al. 2006) with the aim of:

• facilitating a paradigm shift in the way we ‘think and do’ partnership working for wellbeing and health.
• fostering relationships and networks, both amongst those with leadership responsibilities and across the wider partnership community.

The study will work with the data generated as participants carry out the ‘Discovery’ phase of Appreciative Inquiry and will seek to bring to the fore current examples of systems thinking in the practices of those interviewed.

Background

Positive wellbeing and good health are now understood to be the result of a dynamic interplay of a range of social, economic and environmental factors and not individual biology alone (World Health Organisation 2008). Furthermore, in richer countries such as UK, poorer population wellbeing and social inequalities in health are determined by the extent of income inequalities in the society (Wilkinson & Pickett 2010).

These conceptual advances in understanding health pose problems for policy makers and others taking action to improve health. In spite of these new understandings, there are no magic solutions on offer as the complexity of the issue can not be resolved through traditional cause-effect thinking (Exworthy & Hunter 2011). It also requires a shift of focus from individual service interventions to also embrace development and policy interventions intended to improve the wellbeing and health of communities and whole populations (World Health Organisation, Regional Office for Europe 2011).

As this understanding of health becomes more common-place, there are examples of concepts from the discipline of Systems being used in Public Health. For example, Hunter (2009) makes the case for framing health issues through the concept of a ‘wicked issue’ (Rittel & Webber 1973) which “are described as ill-defined, ambiguous and associated with strong moral, political and professional issues” (Ison 2010, p.119). Hunter (2009) goes on to argue that this framing highlights the importance of what he refers to as a systems-wide approach to health improvement.

One application of a systems-wide approach at a local authority level is partnership working. The motivations behind partnership working,in health as well as other policy arenas, include efficient use of resources; the nature of fragmented organisational landscape; the nature of the issues being addressed; and opening up decision making to include citizen’s voice (Lowndes & Skelcher 1998). Partnership working at a local authority level has been central to UK health policy since the 1990s (Perkins et al. 2010). This way of working is set to continue as the proposals in the Health and Social Care Bill (Lansley & Howe 2011) currently before parliament include a statutory requirement for English local authorities to establish Health and Wellbeing Boards.

Research shows that there is not yet any evidence that partnership working results in better health outcomes (Smith et al. 2009). This may in part be because advice on how to work in partnership is rarely based on any theory (Powell & Dowling 2006) and more generally practitioners are likely to glean ‘evidence’ from conferences and official guidance rather than look to published research (Blackman et al. 2011).

Partnerships have traditionally been seen as a hierarchical organisational structure where different multi-agency committees make up the nodes in a hierarchy with vertical accountability relationships between them. Published research suggests the need to re-conceptualise the way we do partnerships, to fit with a framing of health through the lens of a ‘wicked issue’. Parker et al (2010) in a discussion about joined up working at a national level emphasises the need to shift away from the notion of partnerships as over-engineered structures to a more process view that enables relationship building and dialogue.  Blackman et al (2010) comment on the inappropriateness of a managerial ‘command and control’ mentality as it reduces the possibilities for adaptive systems thinking. Elsewhere, there are recommendations that we may need “flexible, looser framework structures that can be adapted quickly in the light of review, learning and evaluation” (Hunter et al. 2010, p.12). I understand this shift as an expression of the movement from modernist to post-modernist thinking in organisational studies which is conceptualised as a shift from an ontology of being (focus on static entities) to an ontology of becoming (focus on flux and transformation) (Chia 1995).

When it comes to how to bring about the change to this new way of working, the area that receives attention is that of leadership (Nowell & Harrison 2010).Hunter (2009) outlines the importance of leaders in bringing about a paradigm change as well as making sure the change results in better health outcomes. Whilst there is an ongoing debate about the differences between leadership in a partnership setting as compared to a single organisation (Armistead et al. 2007), systems thinking is identified as a key dimension of the competences leaders need (e.g. Hunter 2009; Alban-Metcalfe & Alimo-Metcalfe 2010). This emphasis on a competence gap in leaders has led to one English region resourcing an evaluatedprogrammeofleadershipdevelopment (Carr et al. 2009).

The focus on the need for development of leaders (incorporating systemsthinking) seems to be a manifestation of research’s “romance with critique at the expense of appreciation” (Ludema et al. 2006, p.155). My own experiences as a systems practitioner in a partnership setting leads me to postulate that research methodologies have not to date recognised the natural systems thinking capabilities of leaders and other participants in partnerships.

Rather than being absent, I understand these natural systems thinking capabilities as constrained by the setting in which leaders carry out their work. Leaders at a local level are ‘required’ to establish and participate in partnership structures that have been conceived at a national level. Not only may this distract from those involved being motivated by their own purpose (Ison 2010, p.157), it can also distract from a “continually reflexive and self-examining approach” (Hunter et al. 2010, p.119).

A particular constraint identified by Ison (2010) is the target mentality. Blackman et al (2010; 2011) discuss how the English performance regime under New Labour influenced not only the decisions and actions of those with a role in improving health inequalities but the way in which they framed the issue in their discourse. There was a tendency for it to lead to a focus on early detection and secondary prevention focussed at individuals, rather than broader level policy changes where there is less certainty and predictability in terms of outcomes.

This study aims to provide empirical evidence for my claim that leaders are already capable of systems thinking, even if they do not recognise it as such. It will therefore open up possibilities for future research and practice improvements focussed on changing the settings that constrain systems practice, rather than reducing a systemic change agenda to simply an issue of leadership competences.

References

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