Cancer strategy - monitoring and evaluation: participatory systems mapping

Methods

Systems thinking

Systems thinking can lead to a more efficient use of resource and more joined-up thinking as the understanding of complexity increases. This method has been used across government and further afield to tackle a range of complex policy areas. Example case studies can be found in the Systems Thinking Toolkit [8]. More information about Systems Thinking, how it relates to policy development and associated methods can be found here: An introductory systems thinking toolkit for civil servants - GOV.UK (www.gov.uk).

Systems mapping is a method within the systems thinking toolkit for creating a visual representation of a system. The aim of a system map is to explore causes and effects in a system [2]. There are various different ways to approach systems mapping. Two methods were used in this project to collate healthcare professionals perspectives: Rich Pictures and Participatory Systems Mapping.

The Rich Picture method asks participants to draw a “problem situation” from a certain perspective, in order to capture a broad, high-level view of an issue. The goal is that by asking people to use pictures (rather than just words) this opens up how they think about the system [2].

The purpose of the Rich Picture workshop was to gather some initial key factors relating to cancer patients’ experiences in Scotland’s health and care system. These factors were used to kick-start the participatory systems mapping, as well as introducing participants to systems thinking methods. For this project, the problem situation was “Cancer patients’ experience in Scotland’s health and care system”, and participants were asked to draw from their own perspective based on their job role within the NHS. Due to the short project timeframe, and additional information governance that would have been required, patients were not involved directly.

Participatory systems mapping

Participatory systems mapping (PSM) is an approach which aims to tackle complexity by building a visual map of the system while engaging in discussion and exploration of complex issues, and sense checking the implications of suggested causal links [10]. This method captures the interactions and relationships of note to the participants at that point in time, and will never deliver a 100% accurate representation of the system. The aims of the method were to produce a system map that participants are invested in and have ownership of, to produce a visual tool that highlights the complexity and potentially unforeseen consequences of different policy actions, and to end up with a tool that can stimulate and aid discussions, broadening thinking beyond linear pathways. The purpose is not to provide recommendations but to provide novel insights that can be used alongside other ongoing work to develop more robust recommendations in future. More information can be found at PSM Workshop method.

Workshop details

In late January 2024 the networks of the Cancer Strategy Monitoring and Evaluation Advisory Group [11] were used to contact potential participants. These networks were already connected with a diverse selection of healthcare professionals, and these individuals would likely be interested in participating. February 2024 was spent reaching out across the various networks. Workshops were held between March and May 2024.

The aim of the workshops was to gather as many perspectives as possible. When contradicting perspectives were shared these were captured in the system map with neutral connections, and the different perspectives explained in the notes feature. The only factors and connections that were removed were those that were clear duplicates, or those that all participants decided were no longer necessary. This encouraged participants to engage and gain ownership of the system map as it developed.

Participants included consultants covering: haematology, ear, nose and throat (ENT), dermatology; clinical nurse specialists; strategy and transformation; occupational therapy; palliative care. Six of the NHS Scotland health boards were represented. In total 11 different participants attended the workshops. The distribution of participants across the various workshops can be found in Table 1.

The series of workshops detailed in Table 1 were planned such that each covered a distinct chapter in the PSM process. The Rich Picture workshop was used to identify three starting factors. PSM workshop 1 was focused on brainstorming as many other potential factors linking to the starting factors. PSM workshop 2 was focused on linking together the factors and adding/removing factors as necessary. PSM workshop 3 was focused on bringing in the Cancer Strategy policy ambitions and linking them into the system that had been developed. The updates in workshop 3 were then reviewed in the following one-to-one workshops, where further qualitative analysis of the map also took place.

These workshops were carried out online using Microsoft Teams and the purpose-built collaborative mapping tool PRSM. Workshops were organised following a flexible and adaptable approach that allowed us to build on feedback and learning from the experience as the project progressed.

Throughout the process, significant updates were shared with the Cancer Strategy Monitoring and Evaluating Advisory Group [11] for review and comment. A Data Protection Impact Assessment (DPIA) was also completed and checked by the Data Protection team, regarding holding participants’ names and contact details, as well as the use of PRSM as a collaborative mapping tool. A privacy notice was also prepared and shared with participants ahead of the workshops.

Systems map visualisation tool

The static map that was produced in PRSM was exported and converted to an interactive visualisation tool using R Shiny, and shared internally with Scottish Government stakeholders. This was achieved by using a package developed by the Department for Energy Security and Net Zero, specifically for visualising and interacting with systems maps (no reference is available as this has not been published). The purpose of this output is to be an interactive discussion tool, helping users to explore potential impacts of changing factors in the system and how the Cancer Strategy ambitions interact between themselves and the wider system. A selection of representative insights explored using the tool are shared in this report.