Are you making the most of your public health budget.............? There's a tool for that

Over the last few months researchers from Fuse based at Newcastle and Northumbria universities have been undertaking an independent evaluation of one of Public Health England’s published resources, the Prioritisation Framework. In the guest blog below Brian Ferguson and David Gardiner, both of whom were closely involved in the development of the Framework, comment on the evaluation’s findings.

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How PHE’s Prioritisation Framework was developed

Public Health England is committed to supporting local systems to make the best possible investment decisions. With this in mind, in March 2018 we published the Prioritisation Framework, a product aimed at helping local authorities to make the most of their public health budgets. The project to develop the Prioritisation Framework traces its roots back to Shifting the Gravity of Spending? (2015), an academic report detailing how more systematic decision making could be made across public health. From there, the idea was picked up and developed through joint working between Directors of Public Health in the North East of England and their local PHE Centre. After successful prioritisation exercises had taken place in South Tyneside and Gateshead, the foundations of what would be the Prioritisation Framework were taken on by PHE’s Health Economics team to be developed at a national level.

Throughout the development of the Prioritisation Framework there has always been a strong emphasis on user engagement, evaluation of progress and continuous learning. This led to several rounds of user testing throughout the development of the Framework, and we see this latest evaluation by the NIHR School of Public Health Research as another step in helping to shape further work in this area.

How PHE sees the Prioritisation Framework

While the Prioritisation Framework has been developed to be as simple and supportive as possible, it is still easily misunderstood. As you read through the full evaluation report, we encourage you to consider why the Framework was developed, and how it can be used flexibly to reflect local context and needs.

Overview of prioritisation process

One misunderstanding that we often come across is the assumption that the Prioritisation Framework is a ‘health economics’ tool. This is not the way we typically describe it, as the consideration of economic concepts such as cost-effectiveness is only a small part of the information brought together to make prioritisation decisions. Instead, the Prioritisation Framework provides structure and guidance for local decision makers to agree the outcomes they see as important, in a transparent process, that can be tailored and controlled by the users themselves. Any criteria that can be defined and agreed upon by stakeholders, such as equity and political acceptability, can be included and considered. Furthermore, through appropriate facilitation there is the opportunity for effective stakeholder engagement, developing consensus and building influence. In this sense it is much more of a strategic tool, recognising that consideration of the evidence (on both effectiveness and cost-effectiveness) will only be one part of the overall decision making process.

In addition, there is a risk of over-emphasis on the act of assigning numerical scores to the evidence. While this is an important step, it is only a means to an end. More important than the scores themselves are the conversations that run alongside them, where people have a chance to air their views, challenge the assumptions of others and agree on the best course of action through consensus. Capturing these discussions means that the process is transparent, informed and robust.

Users therefore have a significant degree of control when using the Prioritisation Framework. The Framework guides users on how to approach each step, but all the key decisions remain in their hands. This flexibility is critical as ultimately local areas need to have ownership of the process. This also means that each time the Prioritisation Framework is undertaken, the outcomes will be completely unique to the area and the individuals taking part.

The results of the evaluation

The evaluation report yields valuable insights into how the Prioritisation Framework has been and could be used at a local level. Overall, the results are very encouraging and supportive of this type of systematic process. The feedback helps to validate the effort that has been dedicated to developing and implementing the Prioritisation Framework. This effort has extended well beyond the core project team, to the PHE Centres and Local Knowledge & Intelligence teams who have provided support to the early adoption sites, and of course the staff within the sites themselves. We hope that the Prioritisation Framework will continue to be used in these local authorities, and that they continue to provide feedback on their experiences over the longer term.

In addition to thanking the test sites for their kind words, we also want to acknowledge the areas for development identified by the evaluation participants. One issue identified was the time commitment needed. While it is true that the process can be resource-intensive in terms of people’s time, it is robust and evidence-based and is designed to ensure buy-in from key decision makers to help them to make the best use of their public health resources locally. To that extent the work involved can be seen as an investment that should pay off in terms of being clear (for example) about the outcomes that matter to the organisation. This will be particularly true where there is engagement and ownership from senior leaders within the organisation, as acknowledged in the report. There will always be a trade off between rigour and speed, and a balance clearly needs to be struck here. In order to help streamline the process as much as possible and reduce local workloads, the Prioritisation Framework is already heavily supported through guidance and signposting to useful resources.

Some of the other development issues identified have already been taken on board. The thoughts and comments of the early adopters have been instrumental in helping us understand how to better support prioritisation processes. As such, we feel that both the Prioritisation Framework itself, and the associated support from PHE Centres, are in a much stronger position now than when the test sites first took on the challenge. In particular, the guidance and communication on what the Framework can and cannot do are much clearer.

Future developments

Here, several users and developers of the framework discuss how it has supported decision-making in local authorities

Looking to the future, we will continue to make the changes that have been highlighted in the feedback to date in order to further improve the Prioritisation Framework and the support offer. This will include an exploration of how the Framework could be used more widely within local organisations to inform resource allocation decisions broader than the public health budget. We therefore see the Prioritisation Framework as a developing product that will evolve and change over time to keep pace with the needs of local systems. Central to this is understanding over time what impact there has been on outcomes: has using a tool like this actually delivered more value from the limited budgets that are available to improve population health and reduce health inequalities?


About the authors:
Brian Ferguson, Chief Economist, Public Health England
David Gardiner, Health and Wellbeing Programme Lead, Public Health England’s North East Centre

Have you haddock enough?

Posted by Louis Goffe, Research Associate, Newcastle University

That smell. That distinctive saline scent. Your subconscious has your saliva glands brimming before you’re cognisant of what you desire.

Fish & chips is arguably our most iconic contribution to the culinary arts. This most harmonious pairing of Jewish-style fried fish with chipped potatoes, first engaged in the 1860s and have been besotted with each other ever since. At their peak during the inter-war years, there was an estimated 35,000 shops around the country, while in today’s diverse and competitive fast-food market, there remains around 10,500 chippies.

Fish & chips Edwardian style

The interrelating factors that derive our weight are as unique as our fingerprint and untangling and finding solutions is a global challenge. There is no single determinant and competition for a slice of the obesity research funding pie, is as cutthroat as the local high street takeaway shop cluster.

Takeaways are not the prime suspect in unlocking the door to good health, but it’s clear that they do play a role. As such, we need to scope what aspects can change to help provide customers and communities with healthier options.

When it comes to food, there is no universally accepted metric for ‘health’. The term is open to interpretation and keenly fought over, see the fat Vs carbs debate. However, such considerations are rendered obsolete when considering the nutritional profile of independent takeaway food, where meals were found to be “excessive for portion size, energy, macronutrients and salt”. It is the sheer volume of food provided that is the intimidating/wondrous [delete as personally appropriate] factor.

Pizzas are the chart toppers when it comes to portion size, delivering a medium value over 1,800 calories, though fish & chips are not far behind on an excess of 1,600 calories. This is a hefty dollop of energy, given that an adult women is advised to consume 2,000 calories per day. Of course, just because a portion contains this amount of food, it doesn’t mean that one will consume it all. But the evidence is clear “people consistently consume more food and drink when offered larger-sized portions, packages or tableware than when offered smaller-sized versions”.

It was not our assertion that any particular cuisine type is to blame, but to find potential solutions to what has likely been an arms race by traders in response to their most vocal customers to provide the most calorific-kick per quid, as highlighted in this quote from a Scottish fast-food trader.

“They just want chips… they'll have a look and then go along have a look at their deals and then come back and they'll order… they like the value for money. The competition here is unbelievable.”

In our NIHR School of Public Health Research funded study based at Fuse in collaboration with The Centre for Diet and Activity Research at the University of Cambridge, we wanted to challenge the notion that quantity rules above all, to see if traders and their customers were accepting of promotion of smaller meals.

Louis throwing himself into the research

Fish & chips offered the ideal starting template. Their taste is as beholden to us, as espresso is to the Italians, therefore reformulation has limited potential. Despite their volume, they’re presented as a one-person meal, with smaller sizes mainly limited to children, pensioners or as lunchtime specials.

Engaging with traders is a huge challenge. Therefore, we asked Henry Colbeck Limited, an independent specialist fish & chip shops wholesaler, to give the project that foot-in-the-door via a trusted voice. We co-designed the intervention, but crucially, they led on delivery and we retained our independence as a research team for analysis and interpretation of the evaluation data.

We were operating in an intervention landscape reliant on traders’ voluntary participation. This meant an emphasis on the potential financial rewards of provision of smaller meals to traders’ businesses, through articulating the power of customers’ awareness and demand for healthier options.

Henry Colbeck were key to creating a meaningful dialog with and between traders and getting them on-board with the trial. We found both owners and their customers were broadly accepting of the prominent promotion of the lighter meals, with a reported increase in the proportion of smaller meals sales, however our sample size was too small to derive statistical inference.

Lite-BITE box developed by Henry Colbeck Ltd

Interestingly, during interviews with traders, one big question remained, ‘what constitutes a smaller meal?’ During the trial, it was left to traders to define and package accordingly. Concurrent to our independent evaluation, Henry Colbeck sensed an opportunity and developed a new product specific packaging, the ‘Lite-BITE’. They have subsequently sold, along with their partner suppliers across the UK, 12 million boxes in 2018, highlighting that there is the customer demand for a more modest and manageable portion.

Despite this success of raising the profile of smaller meals, how much of them we consume is still unknown and more work is required to better understand the health implications. Also, like the traders in our study, we the consumer, would also benefit from clearer, potentially standardised, portion sizes that could help support nutritionally informed choices.

Our study was formative in nature, but the Lite-BITE box sales show an appetite for smaller takeaway meals and the access to traders that Henry Colbeck provided far out numbers those we could have obtained through door-stepping as academic researchers. We should put all potential tools on the dinner table that could help create healthier environments, including harnessing customer power. So next time you’re in your favourite fish fryer, if it’s not on the menu, ask for a smaller meal and hopefully the owner will soon start to sniff out that saline scent of profit to be made from healthier options.

Louis stars in our video about the research

Image: 'Beamish offers Edwardian-style fish and chips' from BBC Wear 2011: http://news.bbc.co.uk/local/wear/hi/front_page/newsid_9386000/9386156.stm

Igniting my future career with a SPARC

Guest post by Naoimh McMahon, Postgraduate student, University of Central Lancashire

Naoimh recently passed her viva and won Research Student of the Year at the North West Coast Research and Innovation Awards 2019.

Around about now the National Institute for Health Research (NIHR) will be letting early career researchers know if their applications to Round 5 of the Short Placement Awards for Research Collaboration (SPARC) scheme have been successful.

These awards provide funding to allow trainees within the NIHR infrastructure to spend time in other parts of the NIHR to network, acquire new skills and expertise, and establish collaborations with experts in their field. To be eligible for this round of the SPARC scheme, applicants have to be undertaking a formal research training programme, such as a PhD, and be funded by an NIHR award. Additionally, applicants needed to be based in part of the NIHR infrastructure that has a specific remit to build research capacity, such as the NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRCs). In 2017 I applied for Round 4 and while I met both of these criteria, I was also facing the final year of my PhD with a lot of writing still left to do! However, this would be my last chance to apply for the SPARC award and so it seemed like too good an opportunity to pass up.

For my PhD, I was based at the University of Central Lancashire in Preston, and my research was funded through an NIHR CLAHRC North West Coast doctoral studentship. This work was looking at how people negotiate different discourses within the field of health inequalities and how such discourses work to shape thinking and action. With this interest, and a new-found penchant for the North of England, I knew exactly where I wanted to spend my time during a SPARC placement – it had to be in the North East with Fuse! And so towards the end of October, I emailed Professor Clare Bambra (@ProfBambra) to make my case and see if she might be happy to act as my host and supervisor for a placement. After what I can only assume was a glowing reference from one of my PhD supervisors, Clare was on board and we booked in a call to discuss plans for the SPARC proposal.

The requirements for a SPARC award are that you provide a training programme for the placement and you justify the proposed benefit of the programme for your own research and the potential impact for your future career development. After talking through different ideas and options, and considering the short time frame of the placement, Clare and I settled on a training programme oriented around evidence synthesis on the topic of gambling and health inequalities. At the time, gambling was becoming increasingly topical but there was little written about the effects of interventions on social and health inequalities. This focus for the placement was seen as a good fit as Clare had a strong interest in this topic and it would allow me to apply insights from my PhD research to a new body of literature. A co-authored peer-reviewed publication was to be the main output from the placement and we stressed the opportunities provided by the wider Fuse infrastructure for networking during the placement. In March 2018, I found out that my application had been successful and in April I started my six-week stint at Newcastle University.

True to our word, we did exactly what we promised in the proposal! During our scoping searches of the gambling literature we identified a number of recent systematic reviews which synthesised evidence on different types of interventions for reducing gambling behaviour and gambling related harm, and so we felt it would be of value to collate the findings from across these reviews into a single umbrella review. The resulting paper has now been published in Addictive Behaviours. Reflective of the wider health inequalities literature this review has highlighted the lack of consideration of equity effects of intervention strategies in both primary research and evidence syntheses in the field of gambling. Additionally, it has illustrated that there is likely to exist an ‘inverse evidence law’ in this field where there is the least amount of research and evidence for interventions that are most likely to be effective. A big thank you to Katie Thomson (@katiehthomson) and Eileen Kaner (@EileenKaner) for all of their help and input with this review.

 Along with completing this work during my SPARC placement I had the chance to meet people from the Fuse health inequalities programme; get to know some lovely new office mates; attend Fuse’s 10th birthday event and meet people working in local authorities and third sector organisations; meet Fuse Director Ashley Adamson; and attend a Quarterly Research Meeting on eating and drinking patterns in young adults. Last, but certainly not least, I attended and presented my PhD research at the 4th International Fuse Conference which was held in Vancouver in May of last year (see here for a related post on the conference).

In October 2019, the NIHR will launch Round 6 of the scheme and for anybody who may be thinking of applying, here are some things to keep in mind when preparing an application:

• Be ambitious about where you want to spend your time – if you don’t ask you don’t get!
• Develop a training programme that works for both you and your host supervisor
• Try and co-ordinate dates to fit in training or conferences at your host institution
• Detail specific outputs in your application and allow yourself time to get these finished after the placement has finished.

Taking on this type of placement was going to be demanding at any point during a PhD but from my experience it is definitely worth the time and energy. Thank you especially to Clare and Katie, and to everyone at Fuse that made the placement such a positive and worthwhile experience.

Images:

1. Image by Pexels on Pixabay
2. Jeff Kubina from the milky way galaxy [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)]

Is public health ready for complexity?

Guest post by Brian Castellani, Professor of Sociology at Durham University

Public health, presently, is at a difficult crossroads. Its massive success in making the world a healthier place has led to a global embrace of its incredible insights; but still, the challenges currently faced have not given in so easily, as they are deeply entrenched complex problems - or, alternatively, what are more generally referred to as wicked problems!  The global spread of infectious disease; an exponentially growing (or, alternatively, greying) population throughout many parts of the world; the negative impact ecological upset is having on climate and health; urbanisation and the development of mega cities and metropolitan regions; the increasing costs of health and healthcare; air pollution; the opioid epidemic; and so forth.

Still, despite this increasing complexity, public health has been rather resistant to making the shift, falling back on tried-and-true ways of thinking about and modelling public health issues. This is particularly true when it comes to the harsh realities of getting funded or published!  This needs to change! The challenge, however, is how?

Here are, in my mind, six things that public health researchers and practitioners can do to make more effective use of the complexity sciences and advance the use of these ideas across the field:

Six ways to advance the study of complexity in public health

1. Public health is in a difficult position: it realises its work is more complex, but it is struggling to embrace the tools and concepts of complexity science and computational modelling, as it means doing things differently.

• This is particularly problematic in terms of funding streams and publishing in journals.
• The only way forward, then, is to get on with it and actually start funding and publishing such work. High risk can lead to high reward! 

2. Related, the best way forward is for public health to employ a mixed-methods approach, as most public health issues require more than one method, including computational modelling.

• This includes embracing the old and the new, particularly in terms of complex networks, machine intelligence, participatory systems mapping, qualitative comparative analysis (QCA), and agent-based modelling.

3. Public health needs to adopt a critical approach to complexity, as not all methods or theories are equally useful. In other words, the advance of complexity thinking in public health has to be more than the simple application of hard science methods.

• For example, while complex network analysis is powerful, it has significant limits.

4. Public health also needs to develop its theoretical and conceptual understanding of public health topics as complex. This is also true in terms of policy evaluation.

• Not all topics, for example, need to be modelled as overly complex. And there are different ways of modelling complexity.  For an excellent examples, visit the Centre for the Evaluation of Complexity Across the Nexus (CECAN).

5. Public health needs to recognise the important role it plays - both in terms of theory and practical experience - in the development of the complexity sciences, as most of these scholars are trained in other fields. Practitioner expertise, combined with the latest advances in computational methods, will go a long way to improving health. It cannot, however, just be one or the other.

6. Finally, public health needs to adopt a case-based approach to modelling its various complex topics, as health (be it an individual or population) is about cases.

• In turn, it needs to move away from the strict study of variables and variable-based statistics.
• Statistics remains very important for complexity modelling; but variables need to be attached to context and cases and their various path-dependent trajectories.
• Related, the field needs to shift to modelling multiple case-based trajectories, rather than designing a single model.

I want to thank Fuse for the opportunity to present a brief overview of the value of the complexity sciences for public health (and, in turn the value of public health for complexity science!) on 14 February 2019 at Newcastle University.  For those interested, here is a link to the presentation.