A presentation to a National Institute of Health Research consultation event on identifying priorities for public health research for the next five years

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Where next?
Some priorities for PH Research
Prof Jim McManus, OCDS, CPsychol, CSci, FFPH, FRSB, FRSPH, AFBPsS
Director of Public Health, Hertfordshire County Council
Membership Secretary, Association of Directors of Public Health
Jim.mcmanus@hertfordshire.gov.uk
September 28th
2016
National Institute for Health Research School for Public Health Research
Consultation Event

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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

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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)

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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).

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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?

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3 – 8 Year Timescales of social
change
Economy – uncertainty, worsening public finances
Health – Increasing morbidity and prevalence of preventable
disease and avoidable disability. Increasing cost to
system. System strained because unaffordable
Technology – where will this take us?
Resilience – increasing challenges
Social – how is health impacted by changing social
structures, identities and systems?
Systems – systems approaches and what this means for
interventions

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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

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8 Business Rates Retention and Public Health
100% Business Rates Retention – Possible model
Taken from Local Government Association presentation on Business Rates
Retention.

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The LGA’s outlook
www.local.gov.uk

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Some Big Questions for Research to
prioritise
I’m not going to run through all these slides

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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

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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.

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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

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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. “

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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?

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Preventing Avoidable Demand

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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 delay
Need here
Intervene here before need
escalates

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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

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What actually works in keeping people
healthy
What works in reversing costly ill
health?

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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

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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.

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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.

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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.

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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

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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?

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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.

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

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Thank you
• Jim.mcmanus@hertfordshire.gov.uk
• Public Health Pages
• www.hertsdirect.org/healthinherts
• JSNA
• http://jsna.hertslis.org/