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