Project objectives

The project aimed to develop support for local authority based public health commissioners and other stakeholders in prioritising investment in health improvement and tackling inequalities and in deciding on disinvestment. The study also evaluated the use of evidence in the prioritisation process in order to develop broader insights for knowledge exchange.

Changes to project objectives

Changes were due to differences between sites in the extent to which prioritising the public health budget was integrated into decision making across directorates, and issues of capacity and timing in relation to planning cycles. An issue arose in one of the three case study sites, where following a prioritisation workshop held with senior local authority officers, the Director of Public Health held further discussions with the Cabinet lead for Health and Wellbeing. It was decided that rather than going through a prioritisation exercise, it would be preferable to review each bid using local knowledge and judgement to either determine a reduced amount of funding for the bid (variable reductions being applied to the different bids dependent on local knowledge, and indeed local politics) or to exclude bids altogether. Following further discussions with the Chief Executive of the Council and the Director of Public Health about the nature of our involvement with this study site, it was agreed that the provision of additional health economics input was no longer feasible. However, it was agreed that second-phase interviews and observation of key meetings could proceed as planned. Notably, this site focused on corporate values which reflected the local authority as a public health organisation, with plans to use part of the public health budget as a catalyst.

In a second study site, participants decided to use only one prioritisation support session due to a lack of capacity to proceed with the targeted workshops offered.

However, as disappointing as these events were at the time, they proved to be particularly enlightening in furthering an understanding of the newly formed relationships between elected members and public health officers within the reformed public health system, and the importance of tying support into planning cycles and existing decision-making structures.

Further, in the original proposal it was suggested that a workshop bringing together representatives from all three sites will be held towards the end of the project. However, upon completion of the one year follow-on study, we are planning to have a small conference at the end of the project (September 2016) to disseminate the study as a whole to which all those involved in the research will be invited.

Brief summary

Methods

The study adopted a mixed methods approach. Three local authorities across England were selected as case study sites. In each site:

• Through an initial workshop held in each case study site, the relative merits of various priority-setting options were outlined, tools for decision-making identified, and their relevance explored in relation to maximising return on investment, including quality improvement, for health and wellbeing.
• An initial set of interviews with stakeholders (n=29) provided a baseline assessment of methods and approaches in use within each local authority.
• Following the interviews, targeted prioritisation support was offered through health economics workshops that involved key participants in each of the study sites. Site 1 received three sessions of support and Sites 2 and 3 received one session each. There were also a number of planning meetings in each site. Differences in uptake were due to varying organisational dynamics and contextual issues that affected the development of the support offered in each site and determined what ultimately was possible and wanted (or not) in each location.
• The impact of prioritisation methods has been evaluated through a first and second round of semi-structured interviews with the baseline interviews taking place in advance of the health economics support.  The second round (n=19) was conducted between September 2014 and March 2015. Ten of the interviewees had participated in one or more health economics targeted workshops and were invited to comment on the support provided and whether, and how, stakeholders could benefit from it.

In addition, a national survey was sent out to 610 members of Health and Wellbeing Boards (HWBs) across England. Overall, after repeated follow-ups we got 47 responses from 30th September 2014 to 1st December 2014. The survey aimed to identify local authorities who might wish to work with the research team in the follow-on study.

For the one year follow-on study in-depth semi-structured interviews were conducted with the DPH, a public health consultant and an elected member with a role in public health. In addition, priority-setting meetings were observed at one local authority field site. Relevant documents were collected for each field site. 

Results (including findings in relation to the objectives)

The research study, through baseline interviews, the health economics input provided to the sites and second-phase interviews carried out to evaluate the targeted support offered through structured workshops, provided relevant actors with opportunities to reflect on decision-making processes about public health investment/disinvestment. In particular, participants involved in second-phase interviews, and who also attended the workshops that we offered, viewed these meetings as opportunities for dialogue with local partners, and for discussing public health priorities and related prioritisation processes. Both first and second-phase interviews have been particularly useful in highlighting the importance of examining the wider organisational, decision-making and cultural contexts of local government in order to avoid a mechanistic adoption of tools that fail to consider the political priorities, the impact of austerity, everyday constraints of the ‘real world’ and the new role of elected members in shaping public health priorities.

Most participants across the three study sites showed a general understanding of the principles involved in prioritisation tools although elected members were the least knowledgeable. Given the complex organisational structure of local government, austerity measure and varying understandings of public health, participants were sceptical about the impact that priority-setting tools could have on decision-making. While prioritisation inevitably involves value judgements, the study reflected how a new and democratic context for public health priority-setting could lead to different approaches to evidence, to commissioning processes and to how public health was understood. In particular, academic research was found to be only one possible source of evidence; empirical evidence was favoured over information that was not perceived to be relevant to the local contexts and detached from the needs and the issues ‘known’ in the local community. Indeed, political values and priorities are the starting point of prioritisation in local authorities.

Conclusions

The research succeeded in raising awareness of priority-setting tools and in highlighting the enablers and barriers influencing their practical adoption. There is scope for using simple tools in order to ensure that all the relevant stakeholders are involved in prioritisation processes and are in a position to negotiate their contribution. In particular, the findings highlighted the need to forge strong relationships and promote debate with elected members in relation to the public health evidence base, the data available and the sources of evidence that might be used in decision-making. Researchers also need to develop an in-depth understanding of decision-makers’ needs and the local settings in which they operate in order to adequately address context-specific issues.

Plain English summary

Investing in health improvement and addressing health inequalities are key policy priorities. Whether they are reflected in practice will depend in large measure on how commissioners prioritise investment and, particularly in times of economic stringency, how they make decisions about disinvestment. The issue is of particular importance for England whereby the relocation of responsibility for commissioning public health services (through a ring-fenced public health budget) from Primary Care Trusts to local authorities from April 2013 means that priority-setting is now taking place within new organisational and cultural settings. While there are many approaches for prioritisation, their respective strengths and limitations are not well understood by commissioners and practitioners. To date, the application of priority-setting tools in relation to public health investment has been particularly limited, and as such it is crucial to understand the real-world constraints that may encourage, or limit, the adoption of the tools in everyday practice.

This study aimed to provide targeted health economics support to three local authorities and evaluate its impact by using a range of methods. These workshops increased knowledge of priority-setting tools and stimulated reflections on existing prioritisation processes. Positive impact was achieved in one site, where participants decided to use all of the three support sessions that were on offer. Political goals and strategies were found to be particularly important in setting public health priorities and in shaping decision-making processes. Differing, and sometimes contrasting, understandings of what public health involved in practice, as well as of the concept of evidence, were also found to be key factors in shaping views of priority-setting tools and how prioritisation should develop. Austerity was also seen as a practical constraint within which participants had to make choices about public health.

Building on the knowledge gained of the difficulties as well as the potential enablers in relation to public health decision-making in operation within a local government context, these findings will be particularly useful in investigating further how priority-setting tools might be embedded within real-world contexts.

Dissemination

Academic dissemination

Dissemination of work in progress and further engagement with stakeholders occurred through 5 presentations between July and November 2013: the Faculty of Public Health Annual Conference on 3 July (Warwick); the Fuse Quarterly Research meeting on 4 July (Durham University Queen’s Campus); the UKCRC PHRCoE Conference on 9/10th July (Cardiff); the SPHR annual conference on 8th October (London); and the joint Local Government Association and NIHR conference, Money well spent? Assessing the cost effectiveness and return on investment of public health interventions, on 6th November (London).

The abstract for the European Public Health Association (EUPHA) Conference from 19-22 November 2014 (Glasgow) was accepted for pitch presentation. Additional presentations about the study findings are listed below:

• Kings Fund - Public Health VFM Conference, London, 18th September 2014
• SPHR@L Seminar, LSHTM, London, 7th October 2014
• SPHR Annual Scientific Meeting, Sheffield, 22nd October 2014
• LARIA Conference, Manchester, 4th November 2014
• Faculty of Public Health Annual Conference, Gateshead, 23rd/24th June 2015
• International Health Conference, Oxford, 25th/26th June 2015

Our study poster was also on display at the SPHR Annual Scientific Meeting, Sheffield, 22nd October 2014. A poster was displayed at the SPHR Annual Scientific Meeting in March 2016 in Newcastle. 

We have presented the findings of the study at two further conferences since April 2015. These are listed below:

• Faculty of Public Health Annual Conference, Gateshead, 23-24 June 2015
• International Health Conference, Oxford, 25-26 June 2015

An article titled “The return of public health to local government in England: changing the parameters of the public health prioritisation debate?” has been published  in Public Health, 129: 1194-1203 (http://dx.doi.org/10.1016/j.puhe.2015.07.028).

A second article titled “The potential value of priority-setting methods in public health investment decisions: qualitative findings from three local authorities in England” was published in Critical Public Health Volume 26, 2016 - Issue 5. http://dx.doi.org/10.1080/09581596.2016.1164299

London School of Hygiene and Tropical Medicine Blog in relation to the presentation of some of the research findings, 7th October 2014. Link: http://sphr.lshtm.ac.uk/2014/09/29/blog-local-authorities-using-new-responsibilities-shift-gravity-spending-towards-preventive-health/

The Centre for Public Policy and Health at Durham University has a Twitter account, which has been used to promote the presentation of the study findings. The name of the profile is @CPPHdurham.

Non-academic dissemination

Hunter DJ. Shifting the Gravity of Spending? Priority-setting for local authority public health commissioners: Research Highlights. NIHR SPHR Shifting the Gravity of Spending? Workshop to explore methods in public health priority-setting. London, 17 Jan 2017. (presentation)

Gray J. Setting priorities in public health reviewing health economic approaches and reflections from behind the scientists bench and out in the field. NIHR SPHR Shifting the Gravity of Spending? Workshop to explore methods in public health priority-setting. London, 17 Jan 2017. (presentation)

Shifting the gravity of spending? Exploring methods for supporting public health commissioners in priority-setting to improve population health and address health inequalities. Oct 2016. (Second phase interviews: report of qualitative findings) https://goo.gl/OOO9F5

Shifting the gravity of spending? Results of a national survey of selected members of Health and Wellbeing Boards. Mar 2016. (final report) http://bit.ly/1TYs1kp

South J, Hunter DJ, Gamsu M (2014) “What Local Government Needs to Know about Public Health. A Local Government Knowledge Navigator Evidence Review”. Need to Know, Review Number 2, February.http:/www.solace.org.uk/knowledge/reports_guides/LGKN_NTK_PUBLIC_HEALTH_18-03-14.pdf

The study website address is https://www.dur.ac.uk/public.health/projects/shiftingthegravity/

Public involvement

The project was premised on close engagement with commissioners, practitioners and other stakeholders, including local authority officers, elected members, members of CCGs and Local Healthwatch representatives. Our experience confirms a large corpus of evidence on the topic of researchers/practitioners engagement. It is fundamental to establish meaningful engagement with the practitioners from the very beginning of the study, and create opportunities for discussion about its advancement, potential issues arising from it and how they could be overcome collaboratively. We found that public health practitioners were particularly interested in expanding their knowledge of priority-setting tools and, perhaps for this reason, it was easier to establish good rapport with them. Previous interests in the research topic may thus facilitate practitioners’ sustained engagement with a study and positively influence their views on the role of research in improving everyday working practices. We found that elected members were, in varying degrees, more reluctant to engage in meaningful ways with the research team. This was likely due to a variety of factors, including a lack of familiarity and confidence with the research process; lack of time; the need to make quick decisions; gaps in the knowledge base; suspicion about how far they could trust research findings and expertise perceived to be detached from the characteristics and needs of local contexts.

In addition, we also worked with the support of an EAG whose membership included both academic staff with specialist knowledge and skills, and a range of policy partners with implementation knowledge from Public Health England, local authorities and voluntary sector. We received constructive input from our members throughout the course of the study and we believe that this form of interdisciplinary support and expertise is particularly valuable in carrying out a complex project of this kind.

With regards to public involvement, we had several opportunities to present the study findings at various conferences and events. We found audiences with a strong interest in our project, particularly in relation to how prioritisation processes were developing in light of the prominent role that political goals and strategies play in local government contexts.

Impact

The study has increased the evidence base for public health practice by demonstrating which priority-setting tools and techniques might be useful to local authorities, and how these are applied in real-world contexts. The research study, through the health economics input provided to the sites together with first-phase and second-phase interviews carried out with selected participants, has provided relevant actors involved in local arenas with opportunities to reflect on decision-making processes about public health spending. In particular, participants involved in second-phase interviews, and who also attended the health economics workshops that we offered, viewed our targeted workshops as opportunities to conduct a dialogue with local partners and discuss public health priorities and related decision-making processes. We found that public health commissioners’ and practitioners’ reflexivity and critical thinking about prioritisation, has grown through the dialogue and interactions that have occurred amongst themselves and also with the health economists who provided input to the workshops. The study also raised public health practitioners’ awareness of the complexity of the governance arrangements and relationships issues within a local government setting. The study findings could thus be employed to inform training sessions for practitioners’ professional development.

Further, what we learned might be used to strengthen research-policy partnerships in order to create sustained engagement, and trust, between the research community and relevant stakeholders involved in public health related decision-making.

Impact has also been maximised through spreading and sharing the study results with the wider local government community. It will be especially important to add to, and further disseminate, the findings during the follow-on study by selecting various outlets relevant to local authorities, i.e. Local Government Association, LARIA.

Both the main and follow-on studies have had an impact on the thinking of PHE when it comes to designing and implementing future prioritisation tools.  This has been publicly confirmed by PHE’s Chief Economist, Brian Ferguson, who was a member of the study’s EAG.  This link might result in a further follow up study to assess the impact of a new prioritisation framework.

This project was funded by the National Institute for Health Research School for Public Health Research (project number SPHR-FUS-PH1-SGS).

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Public Health Research, NIHR, NHS or the Department of Health.