The Role of the NHS i Prevetio Discussio paper www.fph.org.uk
About this discussio paper The Faculty of Public Health (FPH) has received a grat from the Health Foudatio to udertake a policy developmet ad research project examiig the role of the NHS i the prevetio of ill-health. Our project bega i August 2018 ad will ed i the first half of 2019. This is the first phase of what we hope will be a larger project explorig NHS ivestmet i prevetio. This paper is aimed at FPH members ad other public health professioals workig withi or i partership with NHS orgaisatios, other frot-lie NHS staff or maagers with a iterest i prevetio, eve if it s ot formally part of their role, ad policy-makers at local ad atioal levels. It is the first of three papers that will be published as this project progresses. The cumulative fidigs from our work will be released i a fial report i mid-2019. The Role of the NHS i Prevetio project aims to: Build a better uderstadig of how the NHS curretly delivers prevetio Uderstad what good prevetio i the NHS looks like Explore the eablers ad barriers for NHS orgaisatios seekig to take a more prevetative approach Determie iitial priorities for icreased ivestmet ad focus This discussio paper draws together the key themes that have begu to emerge from our work so far. It also poits to further ideas to be explored, issues that will eed to be resolved, ad steps that will eed to be take i order to achieve our project objectives. 2
About What evidece this discussio did we gather paper to iform this paper? We udertook a diverse programme of evidece-gatherig to produce this discussio paper, icludig iterviewig experts, commissioig a rapid evidece review, doig a review of the grey literature, ad hostig a policy workshop. We have also used evidece geerated over the past few years by FPH s various policy committees. These committees are made up of expert members i all the domais of public health practice. Rapid evidece review We commissioed a evidece review which examied over 400 studies of prevetio programmes withi NHS settigs. We looked for type of activity, beefits, ad barriers ad eablers to implemetatio. Sources spaed 18 bibliographic databases ad covered all four atios. We also udertook a compaio grey literature review. Policy workshop We coveed a policy workshop which brought together over 40 experts i prevetio, icludig from NHS Eglad, Public Health Eglad, local govermet, charities such as Cacer Research UK, FPH s Health Services Committee ad the Health Foudatio. Workshop participats helped us to assess our evidece base ad determie priority areas for this project to focus o. Expert iterviews We followed up the workshop with a series of iterviews with a rage of practitioers ad experts, icludig from Public Health Wales, NHS Trusts, ad FPH s Primary Care ad Public Health Special Iterest Group. These iterviews helped to both clarify ad expad o issues raised durig the workshop ad idetify potetial future case studies for our work programme to explore. FPH expertise We have also relied o evidece geerated by FPH s Academic ad Research Committee (ARC), Health Services Committee, ad Policy Committee, which icludes positio statemets ad survey results. 3
Itroductio The Secretary of State s Prevetio Visio makes the case that prevetio is everyoe s busiess ad caot be delivered by ay oe istitutio, sector, or specialist; we all have a role to play. This shared resposibility is the basic stregth of the prevetio approach ad is a priciple we thik eeds to be at the cetre of the forthcomig Prevetio Gree Paper. But we are hearig from our members workig i differet public health roles i differet places that this broad applicability ca also work as a weakess. If prevetio is everyoe s busiess, there is the risk that it s see as obody s core busiess. This framig ca lead to cofusio over roles, resposibilities, ad obligatios. Commo questios ted to emerge: Who leads? Who is accoutable? Who gets the beefit both fiacially ad i terms of improved outcomes ad at whose expese? Our cosultatio has revealed that it would be more useful to say that while prevetio is everyoe s busiess, it is so i differet ways, at differet times, ad at differet levels withi a complex system. This makes the kid of cross-sector actio discussed i the Prevetio Visio challegig to operatioalise effectively ad at the scale required to make desired populatio level chage i health outcomes ad reduce health iequalities. Bearig that i mid, our focus here is specifically o how prevetio is the NHS s busiess.* We wat to get a better sese of how differet NHS orgaisatios deliver good prevetio itervetios ad where frot lie staff thik the NHS ca add the most value to system wide prevetio actio or priorities i the future. Ultimately, we wat to help the NHS shift from a demad drive system to a prevetio drive oe. We thik the NHS has a pivotal role to play i the prevetio of ill-health ad reducig health iequalities ad should be better supported i those aims. This is ot a ew cocept. There has log bee widespread cosesus that the NHS should be actively ivolved i the prevetio ageda - from Waless (2002), to Marmot (2010), to Steves (2014). Yet, this cosesus has ot traslated ito meaigful chages to ivestmet or service delivery patters. The NHS remais first ad foremost a treatmet service, with the wider health system across the UK spedig oly aroud 5% of its total budget o prevetio. FPH s ivestigatio ito the progress of Sustaiability ad Trasformatio Parterships (2016) foud that most are fallig short of traslatig their prevetio aspiratios ito achievable targets ad commitmets ad that egagemet with public health expertise ad local public health priorities was variable ad ueve. There is ow widespread ackowledgemet that the promised radical upgrade i prevetio has yet to be delivered. So why have we struggled to make progress o somethig everyoe seems to agree o? We have bee challeged by this questio umerous times already. With this paper we hope to start the process of respodig to that challege. I order to do that, this paper grapples with three mai issues. First, we look at the curret evidece base for prevetio ad assess some of the challeges that we see i traslatig this evidece ito actio. We ve heard that while we have good evidece for particular itervetios, situatios, or decisiomakers, overall the evidece base has bee described as mixed i terms of areas ad populatios, limited i scope ad reach, ad sometimes uhelpful for makig populatio level or system chage. For example, there is a cosiderable gap i evidece about metal health itervetios ad also about the impact of differet prevetative approaches o outcomes, the use of health services, ad costs. This meas that decisiomakers ofte eed to go beyod the published evidece whe makig decisios about where or how to ivest i prevetio. 4
The we look at what prevetio i differet NHS orgaisatios looks like i order to get a better sese of the roles that the NHS is playig whe it delivers prevetio. At the momet our members are tellig us that the NHS role i prevetio is ofte poorly defied, poorly uderstood ad, as a cosequece, ca also be poorly delivered. We heard that uderstadig this is essetial i order to support the NHS to take a more prevetative approach. We thik that the opportuities for the NHS to shift from a demad drive system to a prevetio drive oe ca be characterised i two broad ways. The first is via the NHS s role i the direct delivery of services. We kow that betwee 10-20% of our health outcomes are directly attributable to our access to health services ad that approximately half of the prevetio itervetios that people receive occur withi healthcare settigs. We thik the NHS ca make the most of those iteractios by buildig prevetio ito cliical pathways ad workig across orgaisatios to esure services are joied up. The secod is via the impact that NHS orgaisatios ca have idirectly o the social determiats of our health i their capacity as local employers, procurers, ad achor istitutios. This icludes supportig the health ad wellbeig of its ow workforce ad providig a healthier space for visitors, as well as patiets. By lookig at that activity i the roud, we thik the NHS is curretly fulfillig five prevetio roles, albeit uevely ad i differet ways: leader, parter, employer, advocate, ad researcher. We re ow lookig to test whether or ot stakeholders believe these roles are legitimate roles for the NHS to be egaged i ad if we ca better uderstad which roles will help NHS orgaisatios sustaiably shift to prevetio. Lastly, we examie priority areas for actio ad focus over the ext 3-5 years. I particular, we start to egage i the debate betwee those who thik the mai focus should be o supportig NHS orgaisatios to take a systems approach to prevetio (ad what that might mea i terms of immediate actios ad priorities) ad those who advocate the NHS ivestig its resource ad focus i deliverig itervetios that we already kow ca work if implemeted well. Above all, i grapplig with what the priority areas should be we wat to start to focus the coversatio o what will eable big chage to happe. We very much hope that this discussio paper will lead to lots of additioal coversatios with our members, parters ad those iterested i this issue. We raise a umber of questios for further exploratio that we will eed your help i aswerig. These questios are all listed o page 19 of this paper. Please do offer your thoughts via email to policy@fph.org.uk. We look forward to hearig from you ad keepig you updated as the work progresses. * By prevetio we mea the prevetio of ill-health ad ot the wider prevetio ageda, which ca also iclude the prevetio of: demad, admissios, escalatio of care, waste, or cost. 5
Summary of emergig themes This paper addresses three mai themes that have emerged so far from our research, evidece gatherig, iformal iterviews, ad our first stakeholder workshop. 1. What is the evidece tellig us? We have mixed evidece about what works for prevetio itervetios i NHS settigs. While we have good evidece about specific itervetios that are useful for particular decisiomakers i particular cotexts, overall the evidece base for prevetio is limited i scope ad ofte does t meet the eeds of local decisio-makers. This meas that those workig i or with the NHS ofte eed to go beyod the published evidece whe makig decisios about how to implemet prevetio activity or whe they are makig the case to others. 3. Actio ad focus for the ext 3-5 years We heard that a collectio of idividual itervetios aloe will ot achieve the chage we re lookig for at a populatio level. This requires a systems approach. But there is also a eed to prioritise the delivery of prevetio itervetios that we already kow are impactful, cost-effective, ad deliverable withi curret structures if implemeted well. This requires clarity ad aligmet o priority areas for actio ad approaches that should be agreed via cosultatio. Alogside that, we eed a simplicity ad clarity of approach ad commuicatio that ca eable big chage to happe. While this is clearly very complicated, presetig a case that requires a geeratio of political effort ad may billios more i fudig may simply lead to the challege remaiig o the too difficult pile. 2. Defiig the role of NHS orgaisatios i ill-health prevetio We heard that there was a eed to clarify ad better uderstad the various roles that NHS orgaisatios are curretly playig i prevetio. Based o our evidece gatherig, we thik the NHS is curretly fulfillig five prevetio roles, albeit uevely ad i differet ways: leader, parter, employer, advocate, ad researcher. We re ow lookig to test with stakeholders whether or ot they believe these roles are legitimate roles for the NHS to be egaged i whe doig prevetio ad explore i more detail what these roles look like i practice. 6
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1. What is the evidece tellig us? We have mixed evidece about what works for prevetio itervetios i NHS settigs. While we have good evidece about specific itervetios that are useful for particular decisio-makers i particular cotexts, overall the evidece base for prevetio is limited i scope ad ofte does t meet the eeds of differet decisio-makers. This meas that those workig i or with the NHS ofte eed to go beyod the published evidece whe makig decisios about how to implemet prevetio or whe they are makig the case to others. Backgroud We thik that ay actio to improve the health of the public should be iformed by high quality research evidece tellig us what works. To get a better sese of this for prevetio itervetios i the NHS ad to iform the directio our work would take, we commissioed a rapid evidece review that explored three mai questios: 1. What are the mai types of prevetio work researched i NHS settigs? 2. What are the beefits of prevetio programmes i the NHS? 3. What helps or hiders prevetio i the NHS? We also udertook a review of the literature published i o-commercial form - the grey literature - to serve as a supplemet to the commissioed review. You ca read the full results of the review by clickig here, or see the shaded box to the right for a summary of the mai fidigs. Throughout the course of our project so far, we ve bee iterrogatig the published evidece that we ve gathered ad askig people to respod to the mai fidigs. While we discuss the specifics of the fidigs throughout this paper, there are some core themes which have emerged from a geeral discussio of the state of the evidece base that we thik eed to preface the fidigs laid out i this discussio paper. 8 Overview of the Evidece Review Over the past decade, the NHS has take a more proactive role i helpig people to stay healthy ad well ad prevet the oset or further deterioratio of coditios. Prevetio programmes implemeted i the NHS vary widely i scope ad scale, ragig from uiversal screeig programmes to idividual falls prevetio exercises. Most prevetio work that is researched is based i geeral practice or i the commuity; there is much less research o prevetio doe i hospital settigs There is a lack of log-term evaluatio of prevetio programmes delivered by the NHS, makig their impact difficult to assess. For example, the log-term impact of prevetio programmes o health outcomes, o the use of health ad care services, ad o costeffectiveess is ucertai. There are several differet approaches to deliverig prevetio, but there are o clear treds about which are the most beeficial. There are a wide variety of eablers for prevetio work, with good staff traiig ad cross-sector parterships highlighted as particularly importat. However, there are sigificat system-level barriers that eed to be overcome i order to further prioritise prevetio i the NHS. These iclude a lack of itegratio ito core services, the isolatio of staff udertakig prevetio roles, ad lack of ifrastructure ad resources.
What have we foud? 1.1 We heard that the evidece base for public health itervetios i NHS settigs is difficult to traslate ito actio which is a commo problem for a variety of disciplies i may health ad care settigs. This meas that eve if we kow what works we ofte do t always kow how or why it works. This is a fudametal challege for policy-makers ad cliicias, which complicates decisiomakig ad serves as a persistet barrier to improvemet. 1.2 We also heard that i additio to beig challegig to operatioalise, the public health evidece base is also limited i scope ad reach. This is largely because most of the available evidece about what works i health ad care settigs is geerated by research methods that are typically desiged for assessig the effectiveess of cliical itervetios, ofte at a idividual or group level. These methods are less appropriate for desigig itervetios for achievig chage at a populatio level or for addressig public health challeges, which ted to be the result of may complex factors. This meas that while we may have good evidece about a rage of itervetios that deliver specific beefits i terms of cost-effectiveess, retur o ivestmet, or health outcomes for particular groups, that evidece base is less useful for takig actio holistically o prevetio. 1.3 This state of play has led FPH s Academic ad Research Committee (ARC) to suggest that there is a urget eed to grow the public health evidece base at all levels (idividual, group, populatio) withi ad outside health ad care orgaisatios. 1.4 There is also a gap i uderstadig ad/or disagreemets over what kids of evidece differet parts of the system eed. For example, commissioers might eed to see big-picture populatio health outcomes, whereas frot-lie cliicias ofte eed or rely o experietial evidece to tell them a itervetio is workig or is worth ivestig time ad resource i. 1.5 We heard that a lot of prevetio i NHS settigs is delivered i small-scale, short-term, or idepedet projects or is embedded ito routie practice iformally or otherwise all of which ca be difficult to evaluate. Not beig able to evaluate the outcome of routie itervetios, such as Make Every Cotact Cout or social prescribig, has led to what some are callig a egative feedback loop whereby frot lie staff oly get feedback from the patiets whe the itervetio does t work. This leads to a perceptio amogst staff that prevetio is t worth it. 1.6 Research o prevetio itervetios teds to focus o uderstadig or impactig a sigle part of a larger system or tries to strip out system cotext etirely. There is a lack of evidece o how to achieve systems chage i NHS orgaisatios or how specific itervetios i oe part of a system might impact o aother part. 1.7 Due to gaps raised i the above ad challeges of the public health evidece base, stakeholders workig i NHS orgaisatios deliverig prevetio ofte see their role as goig beyod the published evidece to make decisios whe a rage of factors are ucertai. This may iclude usig a rage of less robust evidece, such as case-studies. Key questios for further exploratio: 1. Do you agree with our aalysis of the curret state of the public health evidece base? Are there overarchig poits that you thik we ve missed? 2. How ca local decisio-makers leadig prevetio i the NHS bridge the research-toactio gap effectively? What tools, methodologies, or approaches do they use that allows them to go beyod the evidece they have? 1 9
2. Defiig the role of NHS orgaisatios i ill-health prevetio We heard that there was a eed to clarify ad better uderstad the various roles that NHS orgaisatios are curretly playig i prevetio. Based o our evidece gatherig, we thik the NHS is curretly fulfillig five prevetio roles, albeit uevely ad i differet ways: leader, parter, employer, advocate, ad researcher. We re ow lookig to test with stakeholders whether or ot they believe these roles are legitimate roles for the NHS to be egaged i whe doig prevetio ad explore i more detail what these roles look like i practice. Backgroud There is a cosesus that the NHS has a pivotal role to play i prevetio ad eeds to do more to address populatio health challeges. This priciple has bee most recetly articulated i the NHS Log Term pla process, the Prevetio Visio, ad the Govermet s 2018-2019 madate to NHS Eglad. But what is meat by pivotal is less clear. This is cofouded by the cofusio over what is meat by prevetio as there is o oe sigle uderstadig of it ad also by NHS as there are may differet NHS orgaisatios that ca mea differet thigs i differet places. This makes the role of the NHS i ill-health prevetio difficult to describe. For the purposes of our project, we have defied ill-health prevetio as activities where the primary purpose is to avoid disease ad risk factors (primary prevetio) or to mitigate the progressio of the effects of existig disease (secodary prevetio). But this defiitio is ot uiversally used ad leaves out tertiary prevetio activity as well as, potetially, wider upstream activity. This workig defiitio may be revisited as our work progresses, depedig o stakeholder feedback. Outside of its Sectio 7A services, NHS Eglad has bee pushig a triple prevetio strategy, which ca be broadly categorised as: 1. Targeted prevetio programmes: for patiets at risk of specific log-term coditios, for example the Diabetes Prevetio Programme ad the RightCare CVD prevetio programme 2. Workplace welless: aimed at protectig ad maitaiig a healthy ad productive NHS workplace 3. Healthy ecosystems: providig a model healthy eviromet for NHS staff, visitors, ad patiets While ambitious i scope, ad ofte iovative, the delivery of triple prevetio has bee hidered by the immediate fiacial pressures faced by NHS orgaisatios ad exacerbated by fragmeted pools of fudig that are allocated o a aual basis, restrictive paymet mechaisms, ad a lack of upfrot ivestmet. Itemisig sped is also difficult as may programmes straddle agecies ad are delivered i partership with others. This too ofte masks the wide rage of regioal ad local prevetio activity that idividual orgaisatios are carryig forward, some of which were refereced as priority areas i the Govermet s most recet madate to the NHS. A lack of explicit resourcig for prevetio meas we have o comprehesive picture of where, how much, or to what collective effect this work is beig doe. This lack of trasparecy meas that there is also o clear cosesus about what 10
2 proportio of health system sped for prevetio is required i order to move towards eve a moderate upgrade, let aloe a radical oe. This is particularly relevat ow as the NHS Log- Term Pla cosiders how to best allocated fudig for prevetio. Durig the NHS Log-Term Pla process, Public Health Eglad stressed that the NHS could esure that we all live a loger, healthier life by prioritisig the prevetio of smokig, cardiovascular disease, ad obesity. Other priorities iclude: alcohol, atimicrobial resistace, air pollutio, a healthy NHS workforce, ad metal health. The Prevetio Visio also highlights may of those areas, but prioritises the locatio of care by emphasisig the role that primary ad commuity services ca play ad sigallig that those settigs will be better supported to deliver prevetio i the Log-Term Pla. What have we foud? We have heard that, followig the 2013 reforms i Eglad, there is a sese that the NHS role i prevetio beyod its remaiig core public health fuctios has bee poorly defied ad also poorly uderstood by NHS staff ad their delivery parters. This has bee exacerbated by atioal policy madates, which may be out of step with local priorities or local eed. Reivetig the wheel (e.g. Healthy New Tows) ad droppig the ball (e.g. PrEP commissioig ad STP ivestmet i prevetio) were two phrases that have come up repeatedly. We have also heard that the role of the NHS i addressig people s o-medical eeds ad also reducig iequalities eeds to be more clearly defied. Stakeholders were ear-uaimous that the NHS does have a role i reducig health iequalities as is outlied i the Health ad Social Care Act (2012) ad the Equality Act (2010), but there is a differece i opiio about the shape or extet of that role. Some believe that because prevetio ad health iequalities are closely related, most prevetio itervetios should have the added beefit of reducig iequalities especially if there is a cosistet focus durig implemetatio o reachig disadvataged groups. Published research o prevetio itervetios, however, demostrate that there teds to be lower uptake from harder to reach groups, potetially wideig health iequalities. Others told us that the NHS should pay a much larger regard to reducig health iequalities i all of its activities, but particularly i its capacity to ifluece the wider determiats of health. Related to that, some stakeholders also poited out that there is o cosesus over how far upstream the NHS ad/or the larger Itegrated Care System boudary or remit should exted. 11
What does prevetio i the NHS look like? Added to this sese of ucertaity or cofusio, however, is also a sese that most NHS orgaisatios are ivolved i ill-health prevetio ad reducig iequalities i really sigificat ways, but the evaluatio challeges metioed earlier i this paper mea that the combied extet of this work ad its impact are ofte difficult to quatify or describe. We foud that most NHS prevetio activity targets three broad groups - idividuals, populatios, ad orgaisatios/professioals - ad occurs across four mai spaces - primary, commuity, hospital, ad cross-sector parterships. Regardless of the group or settig, activity ca typically be classified ito 11 differet approaches: icreasig kowledge, supportig behaviour chage, reducig risk factors, idetifyig risk, reducig risk, targetig availability, staff roles, staff traiig, orgaisatioal policies, reviewig provisio/cotracts, ad the use of (usually electroic) support tools. There is o cosesus about which approach is most beeficial. The most commoly researched programmes are those that take place i primary care or commuity care settigs, usually targetig idividuals ad populatios. This kid of activity icludes: 12 Screeig programmes, such as the NHS Health Check Idividual support programmes, such as cousellig or falls prevetio Group educatio, such as group weight loss support Stop smokig services There is much less research published o prevetio i hospitals, but we ca look to the grey literature for a comprehesive overview of the kid of prevetio work that is goig o there. Particularly, we ve foud recet publicatios from Public Health Eglad East Midlads ad the Provider Public Health Network provide illumiatig examples of the kid of work that provider orgaisatios are leadig. Some of this activity icludes: Buildig public health capacity by appoitig cosultats i public health to defie ad deliver public health ambitios Creatig Board level champios for prevetio ad developig strategic prevetio plas Lauchig smoke-free sites Prioritisig staff wellbeig i a variety of ways, icludig through staff wellbeig strategies, healthy food programmes, ad the promotio of the NHS Health Check for staff over 40 Reducig alcohol harms Behaviour chage approaches, such as Make Every Cotact Cout (MECC), health promotio assessmets, ad health chats Promotig equity of care Screeig programmes Actio to tackle the wider determiats of health, such as programmes to support uemployed youg people, providig work experieces, ad procurig services locally We also kow of examples of NHS orgaisatios workig i partership with local authorities, statutory orgaisatios, commercial parters, schools, ad other volutary groups to deliver prevetio. Examples of what this kid of work looks like iclude: Workig with commercial weight loss programmes, such as Weight Watchers or Slimmig World Parterships with the Fire ad Rescue Service to idetify adults at high risk of fires Parterships with local authorities to offer free leisure cetre access Partership with Premier League football clubs to support weight loss for overweight ad obese male football fas What role is this activity fulfillig? Based o our evidece-gatherig, we ve come up with five descriptors that we thik do a good job of categorisig distict NHS prevetio activity. It s importat to stress that this does t mea the NHS as whole, everywhere ad all of the time, fulfils these fuctios. It s also importat to stress that these labels are imperfect descriptors, ofte overlap, ad are a work i progress that we will be lookig to refie as the project cotiues.
5 Roles that the NHS curretly plays i the prevetio of ill-health 1. Leader e.g. commissioig services, providig goverace ad maagemet, settig the atioal ageda, role modellig 2. Parter e.g. providig services, hostig services, workig i collaboratio to deliver services with local authority, statutory, or other volutary sector groups 3. Employer e.g. iitiatives aimed at improvig NHS staff health ad wellbeig; NHS as a commuity employer ad achor istitutio 4. Advocate e.g. lobbyig govermets o public health ageda, lobbyig for prevetio withi idividual istitutios 5. Researcher e.g. fuder ad driver of research 2 Key questios for further exploratio: 1. Do the above outlied roles that the NHS is playig i prevetio chime with your experiece? Have we missed aythig? 2. Do you thik that these roles are legitimate roles for the NHS to be fulfillig? 13
3. Actio ad focus for the ext 3-5 years We heard that a collectio of idividual itervetios aloe will ot achieve the chage we re lookig for at a populatio level. This requires a systems approach. But there is also a eed to prioritise the delivery of prevetio itervetios that we already kow are impactful, costeffective, ad deliverable withi curret structures if implemeted well. This requires clarity ad aligmet o priority areas for actio ad approaches that should be agreed via cosultatio. Alogside that, we eed a simplicity ad clarity of approach ad commuicatio that ca eable big chage to happe. While this is clearly very complicated, presetig a case that requires a geeratio of political effort ad may billios more i fudig may simply lead to the challege remaiig o the too difficult pile. Backgroud I early October, we coveed a workshop that brought together over 40 experts i NHS prevetio. A wide rage of orgaisatios icludig Public Health Eglad, the Associatio of Directors of Public Health (ADPH), ad the Provider Public Health Network were preset, as were academics, FPH leaders, Health Foudatio parters, ad frotlie staff. As part of the workshop we asked attedees to assess our compiled evidece ad the help us determie a short list of prevetio priority areas. We asked attedees to do this for two specific reasos. The first reaso was to support FPH s cosultatio respose to the NHS Log Term Pla. The secod reaso was to determie a broad, but still maageable set of areas for this project to use as a startig poit for assessig where ad how NHS orgaisatios were addig the most value or could add the most value to the prevetio ageda. By examiig these areas, we hope to get a better sese of the roles ad fuctios differet NHS orgaisatios perform whe doig prevetio. We started from a log-list of 26 differet areas, which were grouped ito five differet categories for the purpose of discussio. The categories were selected based o evidece of how prevetio programmes were delivered. The categories were: commo risk factors, cliical ad/or patiet pathways, populatio group or life stage, NHS as a employer, eablers, ad uiversal prevetio programmes. Through structured discussio ad the votig, the log list was arrowed dow to a shortlist of 11. Followig the workshop, members of the project team iterviewed several workshop attedees ad key stakeholders who could ot atted o the day, such as colleagues from Public Health Wales ad FPH s Health Services Committee, to get a better sese of what the short list was tellig us. 14
What did we do at our stakeholder workshop? A guide to the staged process we took to arrive at a short-list of areas 3 Step 1 I advace of the workshop, the project team compiled a draft log list of 26 differet areas for stakeholder cosideratio. The list icludes five categories: commo risk factors, cliical ad/or patiet pathways, populatio group or lifestage, NHS as a employer, eablers for prevetio activity, ad uiversal prevetio programmes. Step 2 Participats add to ad amed the log list Through structured discussio, the workshop participats challeged our draft log list. May participats added to the list ad others reframed the draft categories. Coversatios started to cetre aroud the eed for a systems approach versus what was practical to achieve ow. Step 3 I small groups, participat tables at the workshop chose their top eight from the revised log list, yieldig a collective group short list of 11 priorities. Their selectio is listed below i o particular order: 1. A systems approach to prevetio 2. Better goverace for prevetio 3. Realisig the potetial of the commuity 4. Tacklig iequalities 5. Tacklig multi-morbidities 6. NHS staff health ad wellbeig 7. Metal health ad wellbeig 8. Smokig 9. Alcohol 10. Early years 11. Health promotio 15
What does our prioritised list of prevetio areas tell us? 1. We eed a systems approach to achieve chage at populatio level. Attedees were ear-uaimous that achievig chage at a populatio level requires a systems approach to prevetio. But what does this mea i practice? There is o oe sigle defiitio of a system or systems chage. This meas that people may ofte mea differet thigs whe talkig about it. We see this i the curret published evidece base about system chage withi public health, which sometimes discusses the boudaries of a system i a arrow way (e.g. a cliical care pathway), i a coditio specific way, or i a wider commuity sese. The World Health Orgaizatio (WHO) states that systems thikig is a approach to problem solvig that views problems as part of a wider dyamic system It demads a deeper uderstadig of the likages, relatioships, iteractios, ad behaviours amog the elemets that characterize the etire system. Viewed withi this framework, it becomes apparet that there are two differet types of health itervetios: itervetios with system-wide effects, which ted to focus o a health or care issue, ad system-level itervetios that ted to focus o the buildig blocks of the system, such as the workforce or fiacig. At the workshop, attedees bega the process of figurig out what system-level itervetios we should look to prioritise as part of a systems approach to prevetio i the NHS. This thikig will be developed as the project progresses, but opiio coalesced aroud: Implemetig better goverace for prevetio with the possible exceptio of CQUIN, we heard that prevetio is ot beig systematically drive across NHS orgaisatios by curret goverace practices. Challeges with service specificatios, data collectio ad moitorig processes, performace maagemet, ad cotract maagemet were raised. Realisig the potetial of the commuity commuity services are a hugely sigificat part of NHS activity, but sit awkwardly i curret frameworks that ted to situate commuity services with primary care oly. Icreased ivestmet i public health expertise i healthcare ad populatio health there is cocer over the perceived lack of public health specialist iput ito healthcare plaig ad commissioig. This support is eeded to esure CCGs are able to deliver competet local commissioig of effective ad efficiet healthcare services based o eed. Cross-sector parterships with local authorities, commuity ad volutary sector orgaisatios, commercial parters, ad other statutory bodies partership workig is a system eabler for prevetio delivery ad is oly goig to become more importat as the itegratio ageda gathers pace. There is a eed to examie what makes a partership work well ad how differet NHS orgaisatios behave i differet partership arragemets. Ivestmet to support parterships was also a area highlighted for cosideratio. 16
3 2. But there is also a eed to prioritise the delivery of prevetio itervetios that we already kow are impactful, cost-effective, ad deliverable withi curret structures if implemeted well. Strivig for a systems approach to prevetio does t preclude cotiuig to implemet prevetio itervetios at scale that we already kow ca work if doe well. I additio to the system level itervetios discussed o the previous page, attedees at the workshop listed the followig areas of NHS prevetio activity that they thought this project should explore. They are: NHS staff health ad wellbeig Tacklig iequalities Metal health ad wellbeig Smokig Multi-morbidities Alcohol Early years Health promotio I particular, we heard that we eed to use the above issues to further tease out some of the mai questios this project is iterested i explorig. For example, whe NHS orgaisatios are deliverig early years prevetio itervetios, which roles are they performig? What does good metal health ad wellbeig prevetio look like whe the NHS is performig its differet prevetio roles? This will require lookig ot just at which itervetios go udereath those above listed areas, but examiig how those itervetios are implemeted well. We also heard that we eed to decide criteria for assessig these areas ad/or their itervetios. Are we lookig for areas with the biggest impact? Are we lookig for the greatest cost-effectiveess? Or are we lookig for what is most deliverable? At the time of writig, the NHS Log Term pla has ot yet bee published. However, the process which led to our short list raises some iterestig comparisos with the approach ad priority areas idetified durig the Log Term pla cosultatio process. Public Health Eglad has publicly prioritised the prevetio of smokig, cardiovascular disease, ad obesity as three issues that the NHS must do more to address ad has flagged priority itervetios that they would like to see fuded i the pla. Our prioritised list is much wider tha that ad reflects a sigificat differece i priorities ad approach. Questios for further cosideratio: 1. What does a system wide approach to prevetio across the NHS look like? 2. Do you agree with the prioritised short list of 11 prevetio areas agreed at the workshop? If so, why? If ot, why ot ad what would you chage? I terms of idividual prevetio areas: 3. Are we aimig for the areas with the biggest impact (short, medium, or log-term)? 4. Are we lookig for greatest cost-effectiveess? Ad if so, do health beefits cout as well as direct fiacial beefits? 5. Are we lookig for the most deliverable? Ad do we mea deliverability i terms of how the NHS fuctios, political deliverability, or workforce deliverability? 17
Next steps This project is seekig to examie the differet ways i which prevetio is the NHS s busiess ad the roles that differet NHS orgaisatios play whe they are doig prevetio. This paper is the first iteratio of some of our thikig ad learig so far. It covers issues with the evidece, with defiig roles ad resposibilities, ad with priority areas for actio ad ivestigatio. It does t attempt to provide all of the aswers. Istead this paper deliberately exposes some of the tesios ad complexities that make this area of policy so challegig ad poses a series of questios that we will eed to address to advace this coversatio i a way that is helpful to NHS leaders ad staff, policymakers, ad researchers. We will be usig this paper to cotiue to egage with FPH members ad the wider health ad care commuity over what they thik the NHS role i illhealth prevetio is ow ad should be i the future. To help the discussio eve further we will also be publishig a series of blogs o the FPH blogsite over the comig weeks. You ca read them by visitig https://betterhealthforall.org/. We pla to host two more policy workshops i the sprig i order to cotiue to refie our thikig ad represet the voice of our membership o this issue. At those workshops we ited to examie the barriers ad eablers to good prevetio activity i the NHS, explore what good prevetio activity looks like, ad further refie, clarify, ad expad o the differet roles that will eable the NHS to deliver a step-chage i prevetio activity. After each workshop we will publish aother discussio paper similar to this oe. Ad at the ed of the project we will publish a fial report settig out a summary of everythig we have leared. We hope you will take the time to cotiue to egage with us durig this project ad please do sed us ay feedback about the questios we pose ad the issues we ve raised. To feedback, please email policy@fph.org.uk December 2018 18
Summary of the questios asked i this paper: 4 Theme 1 Do you agree with our aalysis of the curret state of the public health evidece base? Are there overarchig poits that you thik we ve missed? How do local decisio-makers leadig prevetio i the NHS bridge the research-to-actio gap effectively? What tools, methodologies, or approaches do they use that allows them to go beyod the evidece they have? Theme 2 Do the above outlied roles that the NHS is playig i prevetio chime with your experieces? Have we missed aythig? Do you thik that these roles are legitimate roles for the NHS to be fulfillig? Theme 3 What does a system wide approach to prevetio across the NHS look like? Do you agree with the prioritised short list of 11 prevetio areas agreed at the workshop? If so why? If ot, why ot ad what would you chage? I terms of idividual prevetio areas: Are we aimig for the areas with the biggest impact (short, medium, or log-term)? Are we lookig for greatest cost-effectiveess? Ad if so, do health beefits cout as well as direct fiacial beefits? Are we lookig for the most deliverable? Ad do we mea deliverability i terms of how the NHS fuctios, political deliverability, or workforce deliverability? 19
For further iformatio cotact: Lisa Plotki Seior Policy Officer lisaplotki@fph.org.uk I 020 3696 1476 About the UK Faculty of Public Health The UK Faculty of Public Health (FPH) is a membership orgaisatio for approximately 4,000 public health professioals across the UK ad aroud the world. We are also a registered charity. Our role is to improve the health ad wellbeig of local commuities ad atioal populatios. We do this by supportig the traiig ad developmet of the public health workforce ad improvig public health policy ad practice i partership with local ad atioal govermets i the UK ad globally. FPH, December 2018