Institutionalising preventive health: what are the key issues?

By Paul Cairney and John Boswell. This post first appeared on the Public Health Reform Scotland blog.

On the 17^th May, Professor Paul Cairney (University of Stirling) and Dr John Boswell (University of Southampton) led a discussion on ‘institutionalising’ preventive health with key people working with the Scottish Government and COSLA to reform public health in Scotland, including members of the Programme Board, the Oversight Board, Commission leads and members of the senior teams in NHS Health Scotland and Public Health and Intelligence. They drew on their published work, co-authored with Dr Emily St Denny (University of Stirling), to examine the role of evidence in policy and the lessons from comparable experiences in other public health agencies (in England, New Zealand and Australia).

This post summarises their presentation, reflections from the panel, group-work in the afternoon, and post-event feedback.

The Academic Argument

Governments face two major issues when they try to improve population health and reduce health inequalities:

1. Should they ‘mainstream’ policies – to help prevent ill health and reduce health inequalities – across government and/ or set up a dedicated government agency?
2. Should an agency ‘speak truth to power ‘and seek a high profile to set the policy agenda?

Our research provides three messages to inform policy and practice:

1. When governments have tried to mainstream ‘preventive’ policies, they have always struggled to explain what prevention means and reform services to make them more preventive than reactive.
2. Public health agencies could set a clearer and more ambitious policy agenda. However, successful agencies keep a low profile and make realistic demands for policy change. In the short term, they measure success according to their own survival and their ability to maintain the positive attention of policymakers.
3. Advocates of policy change often describe ‘evidence based policy’ as the answer. However, a comparison between (a) specific tobacco policy change and (b) very general prevention policy shows that the latter’s ambiguity hinders the use of evidence for policy. Governments use three different models of evidence-informed policy. These models are internally consistent but they draw on assumptions and practices that are difficult to mix and match. Effective evidence use requires clear aims driven by political choice.

Overall, they warn against treating any response – (a) the idiom ‘prevention is better than cure’, (b) setting up a public health agency, or (c) seeking ‘evidence based policy’ – as a magic bullet. Major public health changes require policymakers to define their aims, and agencies to endure long enough to influence policy and encourage the consistent use of models of evidence-informed policy.

The Panel Discussion

The panel discussion produced a series of positive and sensible suggestions about the way forward, including the need to:

• Make a strong political case for the idea of a ‘social return on investment’, in which every £1 spent on preventive work produces far more valuable long term returns.
• Establish respect for the work of a public health agency in a political context.
• Build on the fact that the broad argument for prevention has been won within Scottish central and local government.
• Ensure a shift in culture, to maximise partnership working and foster leadership skills among a larger number of people (than associated with a hierarchical model of leadership).
• Take forward work by the Christie Commission on reforming public services (such as to ‘empower individuals and communities’, ‘integrate service provision’, ‘prevent negative outcomes from arising’, and ‘become more efficient’).

However, we noted that Christie – and the Scottish Government’s ‘decisive shift to prevention’ – took place eight years ago. We also describe (in Why Isn’t Government Policy More Preventive?) a historic tendency for the ‘same cycle to be repeated without resolution’: an ‘initial period of enthusiasm and activity’ is replaced in a few years by ‘disenchantment and inactivity’.

In that context, our challenge is: what will make the difference this time?

The group discussion

The group discussion took on a ‘world café’ format in which people moved around each space, providing ideas according to theme. The main questions – and three key answers per question – include:

How can we engage well with members of the public?

1. Establish a brand, digital presence, public role, and approach to ‘social marketing’.
2. Choose a consistent model of ‘co-production’ based on what you want from your relationship with service users.
3. Choose how to balance the need to give consistent population-wide advice, and advice tailored to specific communities.

How can we encourage and maintain a public health community?

1. Address perceptions of power and status in the NHS and local government.
2. Clarify what evidence counts, and how to gather and use it.
3. Balance the need for modest ‘quick wins’ (for PHS endurance) with the need to maintain an ambitious advocacy-focused agenda (for community morale).

How can the NHS and local government work well in partnership?

1. Address immediate important issues: contracts of employment, union recognition and support, location.
2. Identify cross-system partnership issues: the boundaries between NHS/ Local authority work, working with local governments directly or via COSLA, how to balance your time between core work and partnership work, and how to work with each other’s stakeholders.
3. Address the possible tensions between national NHS work and local variation and accountability.

How can PHS keep public health high on the ministerial agenda?

1. Use advocacy to generate public attention to evidence-informed policy solutions.
2. Frame solutions in different ways to different audiences, to appeal to national ministers and local politicians.
3. Generate an understanding of how to work closely with stakeholders and policymakers without undermining an image of PHS independence.

How can PHS focus on the bigger picture?

1. Develop a strategy to stay informed about, and seek to influence, policies reserved to the UK.
2. Develop a more detailed ‘health in all policies’ strategy: clarify aims, identify key policymakers, develop a strategy to influence policymakers beyond ‘health’.
3. Develop a strategy to deal with a complex media landscape: from personal relationships with key journalists to less personal messaging for social media.

Post Event Feedback

Feedback from the event was generally positive. Attendees appreciated the time and space to come together with PHS team leaders to discuss next steps. The feedback suggests that the academic presentation helped challenge or shape group assumptions, by:

• Questioning if attendees agreed on key issues. What is prevention? What counts as good evidence? What models of evidence-informed policy should we recommend? From whom should we learn?
• Shifting attitudes about what counts as agency success (survival!) and what strategies help achieve it (such as by stealth rather than always speaking truth to power).

Next Steps

From this discussion, it is clear that Public Health Scotland will happen, and its general remit and ambition is clear. However, to ensure that PHS becomes successful requires grappling with the inevitable dilemmas that confront policymakers – and advisers to policymakers – in such complex terrain. Perhaps the key theme of the reflective discussion was the role of clear choice to address important trade-offs:

1. balancing the imperative to speak ‘uncomfortable truths’ with the need to retain the trust and attention of government
2. pursuing evidence-informed policymaking but with sufficient flexibility to enable cooperation across different approaches
3. choosing with whom to collaborate to maximise impact but maintain credibility
4. working out how to retain long-term support from the public health community in the face of short-term disagreements and disappointments
5. to work for the public (in the background) or with the public (in the foreground) in pursuit of preventive aims.

Some of these strategic choices are more pressing than others. Some can be resolved decisively while others will require an ongoing balancing act. However, each choice requires a commitment to realistic and continuous dialogue and reflection on what (a) PHS can seek to achieve, and (b) what it can realistically expect central and local governments to do.

Public health policy: assumptions and expectations

Rather misleadingly, this very draft paper is called The Politics of Evidence-based ‘Health in All Policies’. It’s for Integrating Science and Politics for Public Health, convened by Patrick Fafard and Adèle Cassola at the Global Strategy Lab.

The most interesting section, for me, is the attempt to sense check the following list of assumptions/ expectations that I associate with public health studies of public policy. Unless stated otherwise, this list is based on literature reviews and documentary analysis underpinning studies of tobacco policy and prevention policy (Cairney and St Denny, 2020), as well as more impressionistic reflections from peer-reviewing many papers on this topic and attending relevant conferences (usually to speak to practitioners about the politics of EBPM). I am relying primarily on (a) the sense, often described in qualitative research, of a ‘saturation point’ to feel confident that more research will not unearth more categories, than (b) counting the frequency of term-use in each category, or (c) network analysis to identify the nature of a self-defined public health profession or community. As such, the focus is on the assumptions that scholars in this field often seem to take for granted, and often do not feel the need to explain. Its purpose is logical and conditional: if these are the assumptions, these are the expectations.

On that basis, I present a common public health narrative of the policy problem, how to understand it, and the processes necessary to address it:

• Focus on preventing ill health rather than treating it when it becomes too severe.
• Distinguish between types of prevention: primary (focus on the whole population to stop a problem occurring by investing early and/or modifying the social or physical environment); secondary (focus on at-risk groups to identify a problem at a very early stage to minimise harm); tertiary (focus on affected groups to stop a problem getting worse)
• Focus on the social determinants of health inequalities, defined by the WHO (2019) as ‘the unfair and avoidable differences in health status’ that are ‘shaped by the distribution of money, power and resources’ and ‘the conditions in which people are born, grow, live, work and age’.
• Promote ‘upstream’ measures designed to influence the health of the whole population (or health inequalities) rather than ‘downstream’ measures targeting individuals (although we discussed some debate/ confusion about the meaning of upstream).
• Use scientific evidence to identify the nature of problems and most effective solutions.
• Define scientific evidence in a particular way, such as in relation to a ‘hierarchy’ in which (a) the systematic review of randomised control trials often represents the gold standard, and (b) systems modelling plays a key role. Or, in fewer cases, challenge that hierarchy energetically.
• Promote major policymaking reforms, including a focus on holistic or joined-up government, since the responsibility for health improvement goes well beyond health departments.  Prevention (or preventive policymaking) is a classic term, and ‘health in all policies’ (HIAP) is currently a key term.
• Focus strongly on the role of industry as ‘vested interests’ causing public health problems (the ‘commercial determinants of health’) and, often, the lack of political will to regulate commercial activity.
• Treat public health and prevention as a form of social protection (new category after PHE). Often, actors describe a moral imperative to intervene (in which case, the opposite argument relates to individual responsibility and opposition to the ‘nanny state’ – see also Cairney et al, 2012 on ‘secular morality’).
• Use tobacco control as a model for other specific issues (e.g. alcohol use, obesity, salt) and the prevention agenda more generally (Studlar and Cairney, 2019).
• Focus on identifying policy changes that represent a ‘win-win’ scenario in which all parties benefit from the policy outcome (in terms of their health), rather than identifying political winners and losers from the policy choice itself (new category – Baum et al, 2014).

Such assumptions underpin expectations for the role of government, and provide a frame of reference for assessing the overall direction of policy (such as for ‘prevention’). Please let me know if there is a big missing category, or one of them doesn’t seem quite right.