nihr sphr take on priorities for public health sept 2016

www.hertsdirect.org

Where next?Some priorities for PH Research

Prof Jim McManus, OCDS, CPsychol, CSci, FFPH, FRSB, FRSPH, AFBPsSDirector of Public Health, Hertfordshire County CouncilMembership Secretary, Association of Directors of Public Health [email protected]

September 28th 2016National Institute for Health Research School for Public Health ResearchConsultation Event

www.hertfordshire.gov.uk

Acknowledgements

Thanks to comments and views from colleagues

•Nicola Ainsworth (SpR)•Cicely Scarborough (PH Project Manager)•David Conrad (Consultant in PH)•Gabi Woolf (SpR)•ADPH UK Board


Context

• Massive Funding Gap in Public Sector– Birmingham £300m– Hertfordshire £167m– STP Footprint £468m by 2021

• Demand is going through the roof• We’ve cut almost as much as we can cut• Brexit....err... (see papers in Science)


Context 2

• Must avoid recent DH research investment going into developing shiny new things that no one can afford

• (https://www.gov.uk/government/news/new-816-million-investment-in-health-research).


Closing The

Financial Gap

Increase Funding

• Increase income levels• Generate new income

streams• Secure new grants• Growth in funding bases

Reduce Costs• Efficiencies• Change service levels (eg

policy changes)• New service delivery

models

Reduce Demand

• Prevention• Triage and redirection

opportunities• Earlier intervention

Framework to categorise measures to close the funding gap in most local authority plans

Invest to Transform Fund

as key tool to enable and service

re-design &cost saving initiatives

Whats a good bet?


3 – 8 Year Timescales of social changeEconomy – uncertainty, worsening public financesHealth – Increasing morbidity and prevalence of preventable

disease and avoidable disability. Increasing cost to system. System strained because unaffordableTechnology – where will this take us?Resilience – increasing challengesSocial – how is health impacted by changing social structures, identities and systems?Systems – systems approaches and what this means for interventions


Epidemiology• Early and avoidable disability and disease• Early avoidable death• Smoking prevalence uneven• Obesity rising in adults, flattening in children in most

places, rising in some• Alcohol related disease on the increase• Preventable cost to public health• Multiple needs, worklessness

www.hertfordshire.gov.uk 8 Business Rates Retention and Public Health

100% Business Rates Retention – Possible model

Taken from Local Government Association presentation on Business Rates Retention.


The LGA’s outlook

www.local.gov.uk

www.hertsdirect.org

Some Big Questions for Research to prioritise

I’m not going to run through all these slides


If I could only have three priorities...

• What will deliver reduction in demand /reduce morbidity/mortality?

• Real world economic returns from programmes• Systems approaches and the role of

behavioural sciences in them


What can we do with what we’ve got?

• how we make better use of existing assets? – This would include self-care, community

based approaches, workplaces, green spaces etc.


Return – “When can I cash a cheque?”Who pays?Who gets benefit?How do you monetarise this meaningfully?•Understanding where any benefits from this activity accrue, and over what period, to the council•Understanding the impact of this work (i.e. does it really prevent future need)•Being able to make decisions about where to invest and disinvest meaningfully1


That big ROI problem - colleague

“top things I’d want to see research on in coming years it would be

a) really good health economics which would give us the evidence to make clear cost saving arguments for PH work and

b) evidence of how to achieve measurable improvements in outcomes through influence, joint working and changes in practice rather than investment (which there won’t be any money to do).

c) I’d also want it to be published in an open access journal so we can actually read it. “


Return on Investment as part of the argument

• Variable response from commissioners to this• Too much use of poorly developed ROI models in

evidence• ROI is not always the answer and sometimes doesn’t

even help• Most ROI models aren’t real world enough• Depends on how robust it is• Who cashes the returned cheque? If agency A invests

but Agency Y gets the return, where is the incentive?

www.hertsdirect.org

Preventing Avoidable Demand


Reducing the need and spend curve: Preventing avoidable spend in public service

Volume of spend

Severity

Existing curve

The Achievable curve?

Reduce or delay need here

Highest cost. Reduce and delayNeed here

Intervene here before needescalates


Which preventive intervention works on which timescale?• The avoidance, whether permanent or temporary,

of need for public service or an adverse event/hazard or exposure leading to need for public service

– SHORT TERM (up to 24 months)– MEDIUM TERM (2-5years)– LONGER TERM (5 years plus)

• Prevention is NOT rationing or restricting eligibility


What actually works in keeping people healthy

What works in reversing costly ill health?


Example: Behavioural Sciences• Review of Research• Synthesis into policy paper• Applying resource• Articulating work and programme plan• Delivery and championing• Integration into strategy

– This is very high level and much more involved in this


Neglected/understudied areas• Populations of identify

– LGBT– Faith/Spirituality

• Integral human development• Interventions for adolescents to prevent mental illness and

increasing resilience to stress/ adverse life events during adolescence and into adult life.

• Adolescence and development – biopsychosocial perspective

• Mental health needs and interventions for poor mental health amongst new immigrant/refugee populations.


Evidence into action...1• Studies designed to demonstrate return on investment (or lack of return)

for ph interventions (necessary outcome / cost data is not often collected or appropriately analysed)

• E-cigarette trials (can they be part of the medications prescribed to help people stop smoking ? what are the adverse effects of doing so?)

• Effectiveness of integrated service models (e.g. services that offer weight management, stop smoking + health checks)

• Trials that helps to make the case for investment in very early prevention activities e.g. RCT with long term (10+) data collection including health outcomes / admissions data on interventions to prevent trying or increasing drug use in young people.


Evidence into action...2• More studies on early social interventions / activities to keep older

population healthy and impendent for longer (e.g. trial on singing group showed positive outcomes in terms of reducing falls but there’s not much robust data out there).

• Studies looking at different funding models for new and ongoing ph interventions.

• Childhood obesity: trial using NCMP data to trigger an automatic referral to an appropriate weight management intervention that does not a lengthy waiting time (pretty sure this is not an option at the moment). Trial needs to assess acceptability to child / parents as well as effectiveness / cost effectiveness.


Disease Management - colleague

• “Obesity as a disease. “ When are we going to start treating obesity as a disease and respond to it in a more multi faceted way? (spectrum of views on addiction/disease on obesity.)

• The future of long term conditions and self-management/ lifecourse optimisation

• Disease lifecourses and preventive interventions


Integrated and Systems Approaches

• Can systems approaches reduce the burden of avoidable disease on public services?

• Can systems approaches improve health? How?

• Can Data Science enhance this?• How do we get actors to act in the way we want

for change?


Technology• The role of technology in health. • mini review posing the question “are weight loss apps as effective as

‘traditional’ weight loss methods?” – by which I meant, does a fit bit or an app do the same, better or worse job than Slimming World or Weight Watchers. I found 1 RCT.

• Research into what the best combination of face to face support and technology would be for lasting behaviour change would be brilliant (not just for weight – but any sort of healthy lifestyle change) we could then commission on that basis.


Two partners in the same dance – i) the research itself and ii) the organisation and its agility


Thank you

• [email protected] • Public Health Pages• www.hertsdirect.org/healthinherts • JSNA• http://jsna.hertslis.org/

nihr sphr take on priorities for public health sept 2016

Health & Medicine