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With organisations across Scotland being encouraged to use a whole system approach (WSA) to deliver the public health priorities, partners are now taking a fresh look at tackling local issues. Public Health Reform has outlined nine characteristics for a WSA. Emma Little, Learning and Development Officer at NHS Health Scotland, gives her take on one of them 'systems thinking'…

“When dealing with a public health issue there are always multiple, conflicting perspectives on what the ‘problem’ is, before even thinking about what can be done to change it.

For example, investment in using Quality Improvement (QI) approaches in process, service and organisational improvement is increasing in Scotland’s public services. Senior colleagues in Health Scotland suspected that:

  • QI initiatives could impact on health inequalities.
  • There was a lack of engagement from the public health workforce in Quality Improvement.

Distinguishing this situation and its characteristics helped to determine whether it might benefit from taking a more holistic systems approach. After reading Checklands soft systems methodology (Howell & Reynolds, 2010), I decided to test his theory in practice by drawing a rich picture of the situation. You can see me in the diagram below highlighted by a red circle which is encouraged when drawing rich pictures. This helped to recognise my place in the situation so I could to understand more about how I might need to adapt to effect change in the situation.


I then analysed the rich picture to begin to distinguish significant relationships. I used a semi-structured interview approach with representatives to reveal the multiple and often conflicting perspectives about the situation. This enabled me to identify themes for further exploration which could be explored further with a growing number of stakeholders.

This simple system diagram is another way to distinguish stakeholders, and their connections and relationships. It’s been drawn and redrawn many times, based on feedback from stakeholders as the number of people who became interested in the situation increased:

I then used the map to identify key stakeholders and engaged them in a conversation to determine whether they thought there was a need to improve the situation and an appetite from them to improve it.

It’s important for the people you’re working with to be able to use tools that work for them. There are always limitations of the tools you do choose, so if you’re aware of them, you can work to address their limitations and work out what other ideas and approaches you need to call upon to fill the gaps.

David Elder from Healthcare Improvement Scotland and I set out to develop a sub-group of Q Scotland (a network to share thinking about improvement practice). We saw this as an opportunity to develop a common purpose with people from both the improvement public health communities. It also meant that we could engage others in the conversation, who brought new examples and new perspectives and helped co-create our theory of change, as you can in the diagram below:

We’ve now identified small components in the system where the changes in our theory of change are ready to test. The skills and experience required of the ‘practitioner’ are now different, and require a deeper technical understanding. I need to remember to keep asking myself ‘Am I the right person for this work? Who else might be better placed? What experience, skills and ideas might they bring?

I’m excited to see how this develops at a different phase, with fresh perspectives and a different type of expertise, as we test systems thinking as part of a Whole Systems Approach to improving public health situations."

Emma Little web.jpg

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