What are the key issues?
On the 17 May 2019, 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.
Governments face two major issues when they try to improve population health and reduce health inequalities:
- Should they ‘mainstream’ policies - to help prevent ill health and reduce health inequalities - across government or set up a dedicated government agency?
- 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:
- 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.
- 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.
- 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 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’.
The group discussion took on a ‘world café’ format in which people moved around each space, providing ideas according to a theme. The main questions – and three key answers per question - include:
How can we engage well with members of the public?
- Establish a brand, digital presence, public role, and approach to ‘social marketing’.
- Choose a consistent model of ‘co-production’ based on what you want from your relationship with service users.
- 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?
- Address perceptions of power and status in the NHS and local government.
- Clarify what evidence counts, and how to gather and use it.
- 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?
- Address immediate important issues: contracts of employment, union recognition and support, location.
- 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.
- Address the possible tensions between national NHS work and local variation and accountability.
How can PHS keep public health high on the ministerial agenda?
- Use advocacy to generate public attention to evidence-informed policy solutions.
- Frame solutions in different ways to different audiences, to appeal to national ministers and local politicians.
- 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?
- Develop a strategy to stay informed about, and seek to influence, policies reserved to the UK.
- Develop a more detailed ‘health in all policies’ strategy: clarify aims, identify key policymakers, develop a strategy to influence policymakers beyond ‘health’.
- 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).
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:
- balancing the imperative to speak ‘uncomfortable truths’ with the need to retain the trust and attention of government
- pursuing evidence-informed policymaking but with sufficient flexibility to enable cooperation across different approaches
- choosing with whom to collaborate to maximise impact but maintain credibility
- working out how to retain long-term support from the public health community in the face of short-term disagreements and disappointments
- 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.