1. School of Medicine & Health The Wicked Issue of Health Inequalities Professor David Hunter

2. School of Medicine & Health For every complex problem, there is an answer that is clear, simple and wrong H L Mencken (1880-1956)

3. School of Medicine & Health Failure of Policies and Systems: Why? Lack of political will – vested interests in maintaining status quo Policy incoherence – push and pull in different directions Systems and structures not fit for purpose Bias towards downstream interventions – lifestyle drift Lack of capability and capacity to tackle to complex wicked issues

4. School of Medicine & Health Paradigm Shift Acknowledge existence of wicked issues Value of a systems approach

5. School of Medicine & Health Defining Features of Wicked Issues (1) Difficult to define – no definite formulation Continually evolve and mutate Multiple causes InterdependentCross-governmental Conflicting goals

6. School of Medicine & Health Defining Features of Wicked Issues (2) Solutions may have unforeseen consequences Unstable Socially complex Solutions are better or worse, not right or wrong Context is all-important

7. School of Medicine & Health Complex 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 agents actions changes the context for other agents. Plsek and Greenhalgh (2001), BMJ

8. School of Medicine & Health Contrasting Approaches Rational, managerial approachComplex 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

9. School of Medicine & Health The Complex Adaptive Leader Manages context and relationships Creates conditions that favour emergence and self-organisation Lets go of figuring it all out Works with simple rules – good enough information and minimum specifications Launches many diverse experiments, reflects on what is happening, instead of trying to figure out the one best way Works with natural attractors and flows rather than always relying on formal structures

10. School of Medicine & Health Wicked Issues and Performance Assessment: The case of health inequalities A comparative study of England, Scotland and Wales Research teams from Durham, Aberdeen and Cardiff universities

11. School of Medicine & Health Constructing Health Inequality Health inequalities were widely seen in all countries as caused by deprivation Focus in England on quick wins driven by performance assessment and availability of models for secondary prevention Target-driven culture absent from Scotland and Wales In Scotland, focus on joined-up government approach to health inequalities In Wales, no driver for focus on health inequalities

12. School of Medicine & Health Is Scotland Showing the Way 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)

13. School of Medicine & Health The 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)