By Lucy Gavens
In September 2019, as the SIPHER Consortium officially launched, the Health Foundation published a report on the need for a whole-government approach to long-term investment in the nation’s health. Summarising extensive work by researchers, think tanks and governments across the world, this report resonated strongly with our understanding in SIPHER of the relationship between health and the economy. Namely:
- Health is fundamental for a strong economy;
- Health is created and protected by strong communities, good education, clean environments, and good jobs;
- Government departments need to work together to deliver a joined up approach to health (since the conditions for good health highlighted in (2) are dependent on the work of multiple government departments); and,
- Government needs to take an active lead in this work.
Examples of good practice
Examples of commitments to joinedup government with a view to enhancing health and well-being are evident around the world. For example, New Zealand’s Wellbeing Budget seeks to break down silos and support cross-government work to implement policies that: improve wellbeing; acknowledge future (as well as current) generations; and track progress via broader measures of success than GDP growth. Another example is the Wellbeing of Future Generations (Wales) Act 2015, which requires public bodies in Wales to consider the long-term impact of decisions, to work better with people, communities and each other, and to prevent persistent problems such as poverty, health inequalities and climate change. These kinds of government interventions create a mandate for joined up action (e.g. by strengthening responsibilities to work together) and provide leadership for prioritising wellbeing across the public sector. This is a positive step.
What more do we know?
Achieving greater coordination across different policy areas has been a long-standing ambition within the UK but, despite recurrent efforts by governments, reviews suggest policymaking struggles to break free from policy silos. Through our work with policy colleagues at local, regional and national government, we have identified some specific barriers to joined-up working across government departments in the UK, that SIPHER is aiming to help address.
There is often a lack of evidence on ‘best buys’ for policy investment, particularly in conditions of uncertainty. In practice, this can make it difficult to articulate and defend the case for taking upstream, equity orientated action to prevent downstream health crises. Furthermore, the complexity and interdependencies of systems linking upstream determinants to health outcomes (which may materialise many months or years later) can be difficult to navigate and therefore paralysing.
Making sure that relevant evidence exists and is available at the right time is also a challenge. Understanding policy cycles (and how they operate locally), how to best communicate relevant evidence to target policy audiences and making sure the evidence is as relevant as possible to the local population are all important for making an impact. And where policies are implemented, there is often limited monitoring of expected and unexpected effects of policies and other system changes to gather robust information to support the refinement, revision or dropping of policies.
Further challenges can be found in the work of SIPHER Co-Investigator Professor Kat Smith who has extensive research experience in policy change for issues relating to public health and inequalities. Kat highlighted key challenges in a 2014 article in Science and Social Policy.
For cross-cutting policy action a key challenge is that government organisations are usually sub-divided into smaller teams that each focus on different policy priorities and this can make crosscutting policy ideas that span multiple teams an elusive goal.
Smith also found barriers relating to the wider policy context, including a widespread perception among researchers, civil servants, policy advisors, journalists and others that there is a dearth of public interest in health inequalities and a general disdain for policies aimed at reducing other types of inequalities. Only 8 out of 112 interviewees claimed any public appetite for more egalitarian policies and no-one claimed there was much media or political appetite for such policies. Yet, it was unclear what these perceptions were based on or to what extent they align with actual public preferences. There is also very little lobbying from organisations and individuals seeking to reduce health inequalities (in contrast to the extensive lobbying that takes place from unhealthy commodity industries).
What are we doing to address these challenges in SIPHER?
In SIPHER our ambition is to develop a decision support tool that supports cross-sector decision making to reduce inequalities and improve health and wellbeing. To address some of the key challenges highlighted by our policy collaborators and previous research we are taking the following steps:
- Co-creating our work with policy partners. By working together to understand their decision-making context and processes we hope to deliver timely, targeted evidence to inform policy making.
- Incorporating public and policy maker preferences for trade-offs across health and non-health domains, and for inequality reduction, to inform understanding of the appetite for more egalitarian policies.
- Identifying and making it easier to navigate existing evidence to support inclusive economy policy decision-making.
- Enabling policy makers across government departments to explore best buys for policy investment through an interactive dashboard that draws on system dynamics and microsimulation modelling to predict the impact of changes in policy areas (e.g. quality of employment, reduced unemployment) on health and inequality outcomes.
- Tracking the impact of policy changes over time to understand both intended and unintended consequences, and to enable policy refinement as and when needed.
This work will support joined up decision-making across the inclusive economy agenda in Sheffield, Greater Manchester and Scotland. Over time, we hope to support other governments who have committed to developing an inclusive or wellbeing economy, such as Wales and New Zealand, through developing a strong evidence base for systems science in healthy public policy.
By Mohammad Hassannezhad & Lucy Gavens
Policy decision-making is most effective when all stakeholders play an active role in the process of problem solving.
Participatory systems mapping (PSM) is a common graphical approach to capturing a range of stakeholder views when exploring way to address societal challenges. PSM offers a process in which stakeholders with different perceptions, expectations, and levels of expertise can work together to develop a shared understanding of a system, how it behaves under different circumstances, and how we might intervene to influence outcomes (e.g. using policy levers).
Shifting towards digitally-enabled systems mapping
Traditional methods of PSM conjure up images of groups of people, often in a fixed place and time, who are huddled around tables covered in flip chart, paper and post-its. After hours of discussing the topic focus of a systems map in detail, workshop participants go home, leaving the organising team to collate ideas and information that has been shared into a map that looks something like this:
Images from Freebairn et al. 2019.
The process can be efficient for small-scale systems with a narrow focus and limited number of stakeholders, but its applicability and usefulness can be challenging for large-scale systems that are not easily bounded. Most importantly:
- The process does not work well for complex systems with potentially hundreds of interlinking variables and many stakeholders. Digital technologies can assist this (i.e. by applying filtered views) to manage the cognitive challenges of mapping complexity;
- The process can be challenging for very busy people with competing demands who may find it difficult to find the time to attend a face-to-face workshop; and,
- The process is difficult when physical meetings are not possible, for example, as we recently found ourselves in the UK-wide lockdown due to the spread of Covid-19.
Complementing the traditional hands-on mapping process with digital technologies can be useful. This can help participants to join the process from anywhere in the world (as long as you can ensure Internet coverage and functionality of web-based tools) and perhaps at a time that is convenient to them. Popular examples include the concepts of Active Citizenship (the use of GIS technology within public participation), Serious Games (the computer games primarily designed for a purpose rather than pure entertainment), as well as web-based simulation tools such as Insightmaker.
The SIPHER approach to systems mapping
Systems mapping is at the heart of our research process in SIPHER. Starting with the topic of Inclusive Economies, we are working with policy-makers and academics to develop whole-systems maps that illustrate the interrelationship between inequality, health and wellbeing. This shared understanding of the system informs various elements of our research including evidence synthesis, microsimulation, and causal system dynamics modelling, as well as the development of our decision support tools.
The case study we describe here is for mapping an inclusive economy in Greater Manchester. Our participants were policy colleagues who work within Greater Manchester, for example in transport, planning and housing, and economic development, as well as academics with research expertise in inequalities, inclusive growth and social policy. From the outset, we collaborated with colleagues in GMCA to design and deliver an iterative mapping process that includes elicitation of data, population of the map (with relationships) and visualisation of outcomes.
Original image from SIPHER GMCA Systems Mapping Workshop
During elicitation, we used a combination of individual interviews with policymakers, documentary analysis, and conversations with policy colleagues to scope out the big picture of the system. We used this information to design a live polling exercise to collect data to understand the relative importance of system drivers in advance of the workshop. This enabled us to pre-populate our chosen web-based systems mapping platform with the factors that our participants felt were important for understanding how developing an inclusive economy might impact on inequalities, health and wellbeing. Therefore, instead of starting from a blank page, our workshop began with a map that looked a lot like this…
Original image from SIPHER GMCA Systems Mapping Workshop
Our first mapping workshop, on the 30th March 2020, was planned as a face-to-face facilitated group discussion using a web-based mapping platform that we designed to enable real-time elicitation of relationships on the map. However, as the UK approached lockdown in mid-March we converted this event into a fully virtual systems mapping workshop. Consequently, elicitation, visualisation, verification, and improvement of the map, have all been managed virtually.
As we are not aware of any other fully virtual interactive systems mapping processes, we thought it might be useful to share our key learning for anyone out there who may be thinking of following in our virtual systems mapping footsteps.
Learning from virtual systems mapping process
Successful participatory systems mapping requires effective communication and collaboration between all stakeholders over the course of mapping process. This can be seen at different stages such as pre-workshop, in-workshop, and post-workshop. In the following, we share some of what we learned at these stages.
Key Point 1: Pre-workshop (preparation)
Before gathering the participants together for the facilitated group discussion, plan considerable preparation time to expose the complexity of the topic system and to synthesize existing knowledge of the system. In our case, this included time to:
- Develop a shared understanding of the purpose of the mapping, including identifying synergies and conflicts in views, key drivers of the system, and enabling policymakers to think about wider influencing factors for their decisions;
- Develop a set of guidance to bound the scope of the map. Our experience of mapping Inclusive Economies shows how the definition and scope can change significantly when looking at a local, regional, or national scale. Be prepared to get very different answers to the same questions depending on who you are talking to;
- Be clear about who your participants are and how they contribute to the mapping process. Ask yourself if the system that you are mapping is a ‘policy system’ (as perceived by the policy community) or an observation of a ‘societal system’ (perceived by a wider community).
We will not dwell on the details of these points here because we believe that you need all of these things irrespective of the way you deliver a mapping workshop, just to say that getting these things right is even more important in a virtual workshop to ensure the mapping is effective.
Key Point 2: Pre-workshop (designing polls)
Given the relatively limited time each person could commit to a workshop (and that spending long periods of time in a videoconference is pretty draining!) we found it helpful to elicit the key variables in the map before the workshop. To ascertain the collective importance that participants attributed to different elements of the map we used a five-point Likert scale (ranging from “not important” to “essential”). These polls could be completed by participants at a time convenient to their schedules.
We used the information shared to develop a prioritisation system for the workshop sessions, identifying the elements that our workshop participants collectively felt were most important. This helped us to make the most of our time together by focusing the discussion on the attributes of the relationship between factors that are important for subsequent quantitative modelling (i.e. directionality, strength of relationship and confidence). The pre-work also support our participants to start to engage with the mapping process in the days leading up to the facilitated workshop, which was a useful preparatory activity.
Key Point 3: Pre-workshop (planning)
It is imperative that the workshop is planned carefully. Really clear instructions should be provided for each role (i.e. leader, facilitator, participant) prior to the workshop. Whereas in a face-to-face workshop it is relatively easy to seek advice or clarification from the workshop leader, in a virtual setting this can be a challenge because:
- It is harder to read body language and other visual cues and so the flow of conversation is more easily disrupted; and,
- Once you are all in different virtual rooms the workshop leader may not be available to you if they are switching between virtual rooms to make sure everything is running smoothly and effectively across the different groups.
It is also important to give participants enough time for each task (e.g. identifying links and their attributes) and that facilitators stick closely to the schedule because making up any lost time if workshop activities go off track can be particularly difficult in a virtual setting.
Key Point 4: In-workshop (interactivity)
Encouraging interactivity in a virtual workshop can be even more challenging than when face-to-face meetings and so it is important to pick the right tools to support your activity. This is not an easy task and there is a considerable body of research already out there on this (read more here). For us encouraging interactivity had two facets:
- Interacting with each other: choose a videoconferencing platform that you are confident in and make sure you have at least one practice run in advance. We found features such as being able to send people to breakout rooms and pull them back together automatically very useful;
- Interacting with the map: we wanted to use an interactive and configurable online mapping platform so that workshop participants could see the development of the systems map in real time. We also wanted our facilitators to be able to use designed scripts and filters, and to take notes all in one place, as part of the workshop activity.
Picking the right tool is a balance between functionality and user-friendliness. It is useful to list your specific systems mapping requirements and then compare available tools to find the one that most closely matches your needs. We could not find one perfect tool to meet all our needs, but it is worth checking out the different options such as Kumu, Mental Modeler, and FCMappers.
Key Point 5: In-workshop (facilitation)
People act and interact very differently in a virtual setting and so to facilitate a lively and productive discussion, we:
- Ran with smaller breakout groups than we had planned in our face-to-face workshop. This required close monitoring on the day to ensure that each smaller group had a good make-up of experience;
- Doubled up our facilitators where possible to help guide the discussion: one for helping people to interact with each other and keeping the flow of conversation going and the other for interacting with the online mapping platform.
These steps were important for giving participants the chance to debate and agree on what the system looks like, which is an important part of the PCM process.
Would we do it again?
Absolutely! Participatory systems mapping is about supporting better-informed decision-making by bringing the diverse expertise on a topic together to develop shared understanding and solution. Geography does not have to be a barrier to this process and effective use of ever-growing digital technologies, with meticulous planning, make it possible to run successful virtual systems mapping processes. This has positive implications for both our current times where we are necessarily remote from one another, but also for pulling together diverse expertise and experiences from across the globe into future mapping activities.