Want to promote good health? Be more oblique

1st February 2013 at 00:00
Sometimes the best way to achieve our goals is to do so indirectly. Wouldn't you agree, Harry Burns?

Sir Harry Burns, Scotland's chief medical officer, argues that the promotion of health has for too long been based upon a deficit model. That is, we tend to focus on identifying the problems and causes of ill health. In turn, this leads to the identification of outcomes all directed towards a particular deficit, eg, reduce the number of people who smoke; reduce alcohol intake; or increase exercise levels. The system is comfortable with these discrete outcomes and develops strategies and activities aimed at achieving them.

Yet the evidence clearly shows that such a deficit-led model has not led to any substantial impact upon those most vulnerable to ill health, ie, the poorest in our society. Sir Harry recommends that in order to promote good health we need to focus on what creates health (salutogenesis) rather than the traditional view of preventing illness.

In order to achieve that goal, people need to be able to understand their lives, manage this day to day, and see themselves and life as worthwhile. People who feel they have little control over life experience more stress. This chronic stress mechanism in the body risks seriously damaging health and quality of life.

In turn, this has led the chief medical officer to propose that we fundamentally shift public health policy towards seeing the assets within people as individuals and in groups within communities, and that we support people to work together and take control of their own lives.

Such a conclusion challenges those of us in public service who have been conditioned over the years to focus upon a simplistic notion of cause and effect, eg, reduce smoking levels by implementing a smoking reduction strategy; or (in our world of education) improve literacy levels by introducing a new reading scheme. This approach appeals to our managerialist tendencies and enables us to set targets, allocate budgets and evaluate success, thereby fulfilling our obligation within the professional management hierarchy.

Yet Sir Harry Burns is not alone in challenging this managerialist approach with its simplistic assumptions regarding cause and effect, and suggesting that a more holistic and seemingly incidental approach can allow us to achieve our goals more effectively.

The concept of "obliquity" (the state or condition of being oblique) was first proposed by another famous Scottish medical figure in the form of Nobel Prize winner Sir James Black, who defined it as follows:

"In business as in science, it seems that you are often most successful in achieving something when you are trying to do something else. I think of it as the principle of 'obliquity'."

Obliquity has been further developed by Scottish economist John Kay, who argues that often the best way of achieving our goals, especially those which are particularly complex, is to do so indirectly.

"Strange as it may seem, overcoming geographic obstacles, winning decisive battles or meeting global business targets are the type of goals often best achieved when pursued indirectly. This is the idea of obliquity. Oblique approaches are most effective in difficult terrain, or where outcomes depend on interactions with other people," wrote Kay in 2004

The paradox presented by Kay is that if you want to go in one direction, the best route might often be to go in another. The irony of his work is that the managerialist aspirations of those of us involved in public service delivery lead us to mirror what we think to be the effectiveness of the rationalist commercial approach.

We set outcomes, we attempt to control parameters, we measure and evaluate, but above all we get locked into doing things the way we have done them in the past and expect different outcomes just because we have planned them better. It was Einstein who described this as insanity, ie, "doing the same thing over and over again and expecting different results".

Yet what we tend to miss is that the world we inhabit is complex and imperfectly understood. Any analysis of our plans would support such a conclusion, given the extent of our certainty that we can succeed where others have failed.

So what has all this got to do with our own complex business of education? Well, from a personal perspective, the concept of "obliquity" strikes a chord in my intuitive understanding of how the world works.

For education is an iterative process that benefits from an open-minded and adaptive approach that values problem-solving and creativity. As soon as we begin to believe that we can make a predictable connection between an action and outcome, we are almost destined to fail. Who was it who said: "Results are what you expect and consequences are what you get"?

Consider the traditional approach to improving the educational outcomes for the lowest-attaining 20 per cent of pupils in our schools - an intractable problem for Scottish education. Typically, we would identify the pupils, plan a range of actions targeted at their deficits, and sit back expecting positive results - and then be surprised when no substantive change takes place.

An oblique approach to the problem would not tackle this directly but would, among other things, address the culture of the school, teachers' values, and the value placed on education in our most disadvantaged communities.

Yet such an approach would take courageous leadership from a school leader, particularly in a professional environment that places undue value on sophisticated plans and confident "direct" action.

Don Ledingham is director of education and children's services, Midlothian, and executive director of services for people, East Lothian.

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