The Government has released a new Drugs Strategy for England, along with one or two other documents . This strategy needs close reading by commissioners and a range of stakeholders. There is some good stuff in it, but also some disappointments. This is my take. Right now I’m feeling 8/10 for aspiration, 6/10 for clarity and 5/10 for action.
Government says that the economic and social cost and changing population drug trends means a new strategy needed. Fewer drug users are coming into treatment and those under 25 who use opiates entering treatment for first time has fallen substantially. By contrast they say, there are more adults leaving treatment successfully but rates vary between best and poorest performing local authorities, and rates have levelled off in recent years with a decline in opiate users leaving treatment successfully. The increase in drug related deaths requires action, but some are still working out what.
The aim is “to reduce all illicit and other harmful drug use, and increase the rate of individuals recovering from their dependence” and they will be “taking a smarter, coordinated partnership approach;“ What’s not to like? Well, this is a mixed document. Some great and welcome stuff, some areas where it remains to be seen what will change and some areas where, frankly, they could have done much better, even without funding. The question I have had in my mind throughout is “will this strategy serve people better?” In some cases, undoubtedly yes. In other cases, much more could have been done.
The logic model of this strategy is an implicit one. Joined up responses and local stakeholders with greater transparency. It is a massive missed opportunity that that significant and positive logic remains poorly, if at all, articulated across this document.
The legitimate role of the state in drugs
There is a debate to be had on what the interest of the state in drugs is. Indeed, there are lots of people who think they’re having that debate. Some of them though, seem to be longer on rhetoric than evidence. The influence of this debate, including the recent (and for my money patchy and inconsistent) report by FPH and RSPH on drugs is conspicuous by its absence. My interest is harm. Where there is harm or potential for harm to people or communities, then we need to act. Where there isn’t, I’m not sure I, personally, have a role. If people are using drugs without any harm or potential for harm, then that’s much less of a priority for me than those who really are harming themselves and others. I’m aware that this varies across government; customs and police have different as well as shared interests to me, and reducing supply remains important even if we only see that as a way of reducing crime. It’s important. But this strategy could have done a basic network analysis of those to guide us all on what we should focus on. That is left to local areas, if it is done at all. And that’s an omission. All of that suggests to me that the policy agenda on this continues to remain short on the joined-up thinking we need to be mirrored at national, regional and local levels.
Responses from the people who will end up doing the work
- “The local response will require Directors of Public Health to continue to play a central role and we can no longer avoid the fact that cuts to the Public Health Grant are damaging to government’s ambitions. There is no long-term vision in this strategy to ensure services are adequately funded.”
- “The pressure on Directors of Public Health and Local Authorities could have been easily addressed by reversing the cut to the Public Health Grant; the announced cuts total £531M while additional expectations continue to be created.”
Meanwhile the LGA response, while affirming that “Local government will continue to play its part in working with national government to deliver on our shared ambition to support those individuals and their families devastated by the harm caused by drug misuse” points out that “we have long argued that reductions by central government to the public health grant in local government that is used to fund drug and alcohol prevention and treatment services is a short-term approach and one that will only compound acute pressures for criminal justice and NHS services further down the line.
It concludes “Leaving councils to pick up the bill for new national policies while being handed further spending reductions cannot be an option. Pressure will be placed on already stretched local services if the Government fails to fully assess the impact of their funding decisions.”
Key things for a Director of Public Health to do
For all the lack of mention of Directors of Public Health (not once in over fifty pages), there are numerous mentions of Local Authorities, and the document implies the system role we have will continue. The key challenge is to turn this strategy from paper to opportunity. That is just not going to happen without Directors of Public Health, local authorities more widely, police, voluntary sector and a range of other stakeholders working together locally. So the lack of even a basic acknowledgement of this beyond the repeated use of the word partnerships is at best, disappointing. At worst, it suggests a lack of ability to think about systems approaches, despite the fact the strategy implies – and here I fully support it – we need whole systems approaches on this.
The key action for DsPH is to identify what we need to do to build effective local partnerships across reducing demand, supply and building recovery and work on this. We should welcome the focus on partnership, evidence and transparency, as well as the lifecourse approach.
We should also recognise that no single agency will in reality be well placed to deliver most of this, it requires comprehensive action by a range of stakeholders. But the role of local authorities and Directors of Public Health needed a somewhat better elucidation than is in the strategy, and to be honest, the role of national government gets little explanation. This document is long on ambition, short on conceptualisation and patchy on action. It will be important for local leaders to fill in these gaps if the ambition and opportunity the document rightly tries to set us towards is to be realised.
At best this document is welcome clarity and focus with very little specific commitment. PHE will face new demands to support. We need to hold PHE to account to deliver this well and effectively, and to add value in the system. That varies by region and Centre, if PHE’s own stakeholder survey views are anything to go by.
Drug related deaths, lifecourse approach, recovery, prescription drug use, chemsex, NPS, working with police, better offender management, drug testing on arrest and more are all on my agenda. Some of this document helps, some of it still leaves us on our own to sort it out. It’s a shame that the leadership role of local authorities in this is mentioned more implicitly than explicitly.
The strategy is owned by the Home Office, but it’s clear this has been significantly influenced by Public Health England.
There is no new money but several re-announcements of existing or previous money. While there is not a single mention of the Director of Public Health, it seems existing funding through Public Health Grant (until 2019) and the commissioning responsibilities of the Director of Public Health will remain.
There are lots of good intentions on partnerships which seem to boil down to a national strategy board to hold local areas and other work to account. While one can see where concerns of different stakeholders have sometimes got through, this strategy feels written close to the chest of government, and what feels like lack of concrete commitments in some places, vague promises of support and work in others shows that. In a time of austerity, why did we not get the system together to work out what we could do without money. I think we would have had a better product.There are a number of things to be welcomed but this could have been a much better document with that approach.
The commitments on Families, for example, are spread across the document but beyond saying PHE will work with drug and alcohol family courts , produce a toolkit for local authorities and an exhortation that “evidence based psychological interventions which involve family members” should be available, there is often not much to go on.
Much of this gives PHE a significantly enhanced role of support or guidance, though some will argue that this is what they should have been doing anyway, and there is little in the way of detail on what will actually happen. The use of “support” occurs 150 times throughout the strategy and “work with” 17. But there is precious little detail and some will wonder about PHE’s ability to deliver.
The strategy seems to verge between a deficit approach “local areas need support” while recognising and exhorting local partnerships to do better at other times. This feels like it could have been better thought through. Its really good they want local areas to be more effective but the relationship set out in here feels extremely one sided. Will local commissioners have representation on the new national Board? If not, why not?
For all their talk on partnership and integration, the model still feels like it veers towards national doing to local and holding them to account.
Measuring outcomes gets various mentions with, on page 36, its strongest statement, a framework of measures and outcomes from treatment to recovery. A homelessness and housing measure, and measures for crime, mental health and employment will be added. Without the impetus or requirements for agencies to work together though (and this never gets beyond exhortation in the strategy), this will be more difficult to achieve if local relationships and co-ordination don’t prioritise this. Good idea by government, but have they really thought through how to make this drive change?
A section on governance is perhaps most disappointing of all. Given everything that could be done locally to address some of the aspirations of this strategy, there is only a commitment to a national strategy board (fair enough, that will be useful) which will “ use greater transparency and data on performance to support action by local services to deliver the best possible outcomes and monitor progress.” The old National Treatment Agency’s obsession with performance management by another name perhaps?
There will be a National Recovery Champion who will sit on the Board, provide leadership, support collaboration, seek to address stigma and act as a ministerial envoy. Well, as a change tool, this has mixed reviews. Has government learned little from the mixed experience of Tsars, Czars and Tzars across clinical areas, public sector transformation and drugs among other areas since 1994?
The statement that “the Care Quality Commission will play a vital role in assuring quality” is very welcome, provided CQC does better at understanding what it is we are all trying to achieve. The document talks about quality in an encouraging way. That’s good. But we need to work together to recognise it, and there is little concrete here to go on. Take for example what good looks like for specific populations. There are sections on specific populations across the document. These range from really welcome but could be stronger (dual diagnosis issues) to tokenistic and feels like government doesn’t actually know what to do (chemsex.) The phrases “good practice” appear throughout. What this looks like across any area remains to be seen.
I’m not going to cover the global action chapter which feels more like its relevant to people other than local commissioners.
Reducing Demand – adopting a lifecourse universal approach
I count at least 20 commitments in this and other chapters on this:
- PHE will help local areas by providing professional guidance for midwives, health visitirs and school nurses under health child programme
- Providing support and guidance to LAs including systems to support integrated commissioning and delivery from 0 to 5
- Supporting school nurses, youth workers and community services to work together
- Providing information through child health profiles
- Encouraging schools and teachers to “develop their practice”
- Encourage prevention strategies in schools
- Develop resources and share them, and monitor existing programmes
- Specialist substance misuse services should link with wider childrens’ services
- Govt says they will support youth offending team to work with individuals
- Action on families : PHE will wotk with Family Drug and Alcohol Courts and local public health teams to improve outcomes and the existing Troubled Families programme. No mention of Family Safeguarding. The strategy later commits that PHE will develop a toolkit for LAs to support response to parental substance user
- Vague and unsatisfactory commitment on intimate partner abuse (page 12)
- In depth research on sex work
- Homelessness work will be done through the Homeless Prevention Programme (but nothing specific on drugs)
- Expectation to continue to work together on veterans drugs issues nothing concrete other than provide tailored pathways
- On Older People Advisory Council on Misuse of drugs looking at evidence on older people
- On new threats they talk about novel psychoactive substances (NPS) and will establish a new clinical network of experts and clinicians.
- In prisons NHS England has carried out a review of its commissioned provision and will increase focus on NPS
- Neptune II – an NPS programme, will be promoted more widely across the field
- Chemsex – PHE will support areas by providing guidance on close collaboration between sexual health services and community groups
- Misuse of prescription medicines – “we will support local authorities and CCGS so people dependent on medicines can access suitable treatment”
Some of this is good, some feels like a litany of “things we must mention” rather than a coherent set of strategically thought through concentrations of effort. Little of this seems to have much in the way of strong evidence base and the strategy seems to assume beyond pilot areas mentioned that it isn’t happening already. Some of this may be useful but this feels like doing for the sake of doing. Phrases like “encouraging” schools, seems to have little in the way of teeth given how government feels this is urgent. Some encouraging noise about universities’ role are given, for example, but no clear action. There is an incredibly weak statement on prescription medicine use especially given what others are doing about it
Restricting Supply Chapter
There are some new actions but mostly targeted at national level. Some specific commitments to be welcomed include:
- Govt will look at options to make improvements to drug driving regime including remedial courses
- Look at how anti social behaviour legislation can be used to tackle drug related offending
Sub chapter on Drug Related Offending
This section is mixed. There are some good things in here and if we work on them we could make the system work better. Some things need greater elucidation, though.
- Encouraging wider user of drug testing on arrest.
- push for drug testing to be more consistently available in the community so it can be part of a community or suspended sentence (feels like a backwards move for some areas)
- Early intervention for offenders through “better integration” with community mental health and substance misuse services
- Increase use of treatment as part of a community sentence including a protocol for drg rehabilitation
- Considering what to do following the pilots on out of court disposals
- Against the background of prison reforms, do more to restrict supply in prisons including testing and treatment. A specific list of actions and committments
- Some vague statements about local partnerships
- They will work with integrated offender management arrangements to share practice
- Continue to support heroin and crack action areas
We need to turn some of the very vague statements like “we will work with” into concrete actions. This section of the strategy seems strongest on the national enforcement and supply restriction work and work in prisons. Buzzwords like better integration and vague words about local partnerships are welcome signs of intention but we need to turn these into action. The National Strategy Board will not achieve this unless it develops strong local relationships.
This is, sadly, probably the weakest chapter, even given the welcome but weak lifecourse section. There is a very welcome reminder of support after people finish treatment and a useful (page 31) and a list of points on things to enhance recovery. I like this checklist. A good highlight is an emphasis on working from custody to community and actions to reduce drug related deaths.
But other than one or two pieces of action, it feels largely like most local commissioners are left on their own with the promise of PHE “support.” All in all a missed opportunity for government to play its part much more synergistically with local commissioners.
A section on commissioning starts by saying nobody should be left behind, confirms the extension of the ringfenced public health grant to 2019 and says there will be greater transparency through building on the Public Health Outcomes Framework to “hold local areas to account” and then talks up the £30m Life Chances Fund and £10m payments to homelessness prevention programme. While the latter is very welcome, this section seems to say little of any use. Again, some useful pointers but it’s up to local areas to make of this language of intention what they can.
Later in the strategy they commit to expanding the measurements of outcomes and treatment indicators (page 36), which could be very useful for commissioners and local stakeholders. Transparency is good.
I support recovery as part of response to drug and alcohol use. I really do. But evidence for recovery approaches is still building and in some areas is patchy, so the statement that ACMD has been looking at the commissioning of drug treatment and recovery services and the impact this can have on recovery outcomes for individuals and communities is really welcome. We need much more evidence and improving practice. But they could have recognised here that actually some of the providers around the country are doing amazing work. The commitment to “carefully consider any recommendations to inform future policy” from this while welcome, feels a let down given how important this area is. We need to be even more dynamic as a field on building and implementing evidence of what is effective. Government’s leadership role in this alongside the rest of us is not well articulated here.
A re-iteration of need for local partnerships contains no specific commitments on doing anything to support them. The 2007 guidelines on commissioning have, however, been updated, which is welcome. PHE will support and share guidance and there will be a broader set of indicators (feels like they’ve already said this several pages earlier.) Commissioners “should” develop quality governance structures for drug treatment linked to safeguarding procedures for children and adults. (page 30.) The advice that we address quality in rehabilitation and detoxification is welcome . But there is no indication of what quality looks like and this strategy is not going to give us it. The proof will be in how agencies work together.
This is a major issue in our field. There is a welcome statement on ensuring we continue to have the right workforce including working with HEE and Royal Colleges. What will the National Strategy Board to do support this is my question back?
In particular I welcome the statement that Government will “work with Health Education England and other stakeholders, in line with the Five Year Forward View for Mental Health recommendation, to support development of an appropriately trained and competent workforce to meet the needs of people with co-occurring substance misuse and mental health conditions. “
If these commitments happen, it will be all to the good and it’s good the strategy recognises that.
Perhaps one of the most long awaited announcements has been the outcome of the Dame Carol Black work on drug use and employment. Nothing really new here. Universal Credit will still roll out, JobCentres will have a “transfored roled” and a new “Work and Health Programme” will provide support to people who are long term unemployed and give early access to people with drug issues.
Finally, I strongly welcome the recognition of user engagement but this could have been better phrased. The section on peer-led recovery, by contrast, feels weak and beyond a mutual aid toolkit for peer support exhorts local areas to “support community based initiatives which promote and sustain recovery”
It feels like strategy is flavour of the month. (That’s not a bad thing.) Our own second Public Health Strategy for Hertfordshire is in consultation right now, and I have been asked to help with Strategy development for two national voluntary agencies I work with and a major local charity. Meanwhile the County Council’s Corprorate Management Team had a strategy afternoon (always useful) and the Prevention workstream of the STP has to deliver its prevention workplan. Strategy is ever present. It must be the end of the financial year!
Yesterday a very enjoyable and enlightening twitter conversation was started by J Thompson-McCormick on public health strategy, which prompted a range of folk I respect and whose views I learn from to tweet their take on strategy. What struck me was the variety of takes, but some ever present common themes.
That prompted me to do a bit of reflective learning. I produced my first strategy in 1990 as a new local government officer. Since then I have lost count of the number of strategies I have led, had a hand in or simply advised on.
When I came to Hertfordshire I led the process of our Public Health Strategy in 2013. I learned that Hertfordshire likes a “plan on a page” – whatever you do a graphic representation helps. This year I had nothing of value to add when my team did the work with others and did it brilliantly. To me that’s success. They get it. Actually being able to let them do it and clear the space for them was my most useful contribution. What that showed me was that there probably isnt enough space to put a cigarette paper between my ambitions and those of my team. I couldn’t be happier about that.
Some folk think our first Herts Strategy was too detailed ( to be honest. it’s somewhere between a strategy and a business plan) but it does have a strategy on a page. And it was detailed for a reason – Public Health was new to local government and I had to both set out our stall and get permission to do things. I don’t need to make it so complex now. Strategies and our approach to them should adapt and change with circumstances. Now I have to work out how we deliver public health in a very straitened set of financial circumstances and a different partnership and governance world. Some fundamental drivers for our strategy (money, partnerships) have changed. Our approach to what the strategy looks like must too.
The absolute fundamentals
What nearly thirty years of doing strategy has taught me is that there are multiple ways to do strategy, and the acid test is whether it gets you to where you need to be as an organisation.
When I worked in the private sector we had people who used the Strategic Planning Society knowledge and people who used Operational Research techniques, and indeed these can be crucial in the mix of doing good strategy.
I’m convinced that the private sector remains better at intersectoral collaboration – read partnership – than much of the public sector. In my experience private sector partnerships are driven by constantly articulating and driving out the value to each partner, however that is expressed, rather than having a competition about who can fit the biggest pile of caring-sharing management speak into strategies. We could learn an awful lot from that.
The fundamentals of strategy
I think there are only seven fundamentals of Strategy, and those given below are mine. I don’t expect anyone else to agree. I still find a Harvard Business Review article from 2010 on the Five Questions of Strategy hugely useful. That piece begins with the sage advice that “People make strategy more than it needs to be.” There’s a fairly similar piece in Forbes I like to refer voluntary groups to. NCVO produces four extremely good and short videos on strategic planning for the knock down cost of £8.99. These are brilliant and I have used them many times with groups. So use what works for you, don’t assume any single person has THE formula.
1. Does it get you to where you need to be given the context you face? (And no, let’s not analyse that to the nth degree right now.)
2. Does it deliver the value you need, however you conceive that? (partnerships, outcomes, services, income)
3. How do you do it with the least cumbersome set of paperwork and processes? If you have to read across nine documents to work out what you need to be doing, you’ve probably got something wrong. Anyone who tells you rigidly you must have a strategy, a business plan, a delivery plan and a suite of strategic action plans may have it right for them, that doesn’t mean it’s right for you. There is NO hard and fast rule here. A strategy should ideally be a simple high level document with a “how will we get there” plan underneath. But if you combine the two, then that’s fine. That doesnt make it bad strategy. Failure to get results makes bad strategy.
4. Do the science (information, data, numbers, evidence), the art (influencing, leadership, stakeholder views and values) and your instincts (this feels and looks right given the issues we face) chime to tell you across all three of those domains this is right?
5. Strategies live and breathe and change, so expect to be in a different place by the time you get there. The key is whether you adapt as you go.
6. At a glance – can you graphically summarise and represent your strategy on a page? No? Then it’s too complicated.
7. Leadership and culture. The English public sector context is now such that leadership across distributed functions and responsibilities is the key to outcomes. Running empires is a dead leadership tactic for a passed financial era. (That doesn’t mean you let others control you or your budgets. Be a strategic dealer, not a doormat.) Writing a business plan entirely on your own without any reference to anyone else (step forward several bodies we could all name) shows a signal lack of understanding this. Leadership which is about getting my organisation somewhere without reference to others is folly. Leadership which is about ensuring my organisation and others get to where they need to be is hard work, frustrating but essential. Producing a strategy in secret then expecting stakeholders to sign up (the early STP process) is just about the worst way possible to develop strategy and doom it to failure. Do the exact opposite of what NHS England did in directing Sustainability and Transformation Plans in their first six months and I suggest you won’t go very far wrong.
I still think the best strategy I ever worked on was the Catholic Church’s national strategy on influencing healthcare. (As background, in case you’re wondering, over 200 care homes and facilities like counselling centres, with 3,500 projects are run from over 300 Catholic agencies in England and Wales, contributing an estimated £1.2bn of value to health and social care. Recent analysis of ONS data suggests that, compared to their size in the population, Catholics are eight times over-represented in the health and social care workforce in England. )
We had three priorities, suggested by Anthony Levy (an atheist, incidentally) , a man who’s done more strategy than I’ve had coffee, and whose style, take and modus operandi I just love:
- Gathering – bringing people together to support each other and influence others;
- Guiding – articulating why based on ONS data, Catholics are eight times overrepresented in the health and social care professions compared to the general population, the values behind that and why a belief in human dignity drives us to work in health and social care
- Giving voice – Showcasing work, celebrating good practice, sharing what we do
Those three priorities, three years on, spurred action at national and local level with over 200 projects. And we monitor progress and impact under those three themes. Consultant clinicians, bishops, domestics and policymakers worked together to produce it. We start the next strategy process in April 2017.
Getting to a good strategy
So, if those are the fundamentals, how do you get there? In reality, there are multiple ways, and I don’t think I’ve ever stuck exactly to any single formula. The only must do is include people who are relevant – people who will deliver it, stakeholders, end users of this, politicians, leaders, anyone you expect to have on board. I once started a strategy process by gathering people who couldn’t agree round a blank flipchart, said “what do we want to achieve? And we’re not leaving the room till we get agreement” and they produced a very clear set of five strategems within two hours, with some robust facilitation!
On another occasion I got buy in from a group that I would produce an initial rough position paper that they would rip apart and put back together again. And they did. Usually I like to start with someone describing the situation and context, mutually identifying some principles of what will get us through, and then getting the group to articulate and produce a broad framework. And then, usually, you have to have a small group work up the detail and come back for validation, amendment and augmentation. Strategy by committee is painful. Strategy by whole town meeting is impossible.
Where on earth do I start?
Why not start with reading the Farnam Street Blog piece A primer on strategy and then some of the links below? You may or may not then wish to read Richard Rumelt’s book Good Strategy, Bad Strategy if you have the time and inclination. Then you need to decide on i) what you want to achieve and ii) a process to get there (but one you can change if you need to, in order to get the outcome right.)
The Process of Process
I think however you do it, you need a process to get a strategy. That means you need to understand, get folk to agree, and then steward the process you’re using. I like to answer the questions below (and adapt as I go along) so we get a good strategy. You might find the wickedly helpful Dummies.com strategic planning toolkit for dummies helps. And I know people in private, public and third sectors who’ve used this at my suggestion and say it works. I’ve adapted some of these principles from a book by Aubrey Malphurs first published in 1999. Others are my own
- Who are we?
- Why do we do what we do? (Values)
- What kind of world are we facing?
- What are we supposed to be doing in that world? (Mission)
- What are our must dos?
- What are our would like to achieves?
- What kind of organisation do we need to be to survive? (Vision) What values do we need?
- What will success look like? (Outcomes)
- How do we measure progress?
- How will we get there? (Priorities)
- What tools, resources, skills, processes and partnerships do we need? (Leadership, Culture, Skills, Deliverables.)
- Who do we need to engage to get a strategy out of this which people own?
- How do we make sure we adapt as we go along, and deal with pleasant and unpleasant surprises?
If I had a top tip
If I had a top tip on strategy, it is this. Everyone sweeps and looks forward to the future. Very few when they’ve done that then sweep backwards from the future to today, to see if the plan falls apart, which it often will. Sweeping forwards, then backwards, then forwards to correct is essential in my view.
The role of anyone leading a strategy process is one of stewardship. This isn’t “your” baby. It’s a process you are holding to get a group of people or agencies to a strategy that they can own and invest in. “This ain’t about you, princess.” If you can get folk to buy into this, and it feels right, then you’ve done your job.
Reading and learning
There are multiple tools and books out there. There are expensive courses and Master’s degrees and for some agencies these are useful. For our purposes they’re probably overkill. I’ve tried to point you as I go along to the cheap and the free and the valuable above. In addition to the resources above, some people find the On strategy stuff useful. Bear in mind though they are trying to sell you their strategy and performance software. Roger Darlington has a beautifully simple take. HBR’s 10 must reads on strategy is good.
You don’t need massive sets of books and consultancies on strategy for most purposes. Business plans and project plans and delivery plans or whatever you call them need detail in them. Strategies need to blend high level and detail to do them well. In my view this is better produced by the people who will own it with a person or people leading process. Externals, if you use them, are often best to facilitate agreement and ownership rather than write it.
Registration is now open for this webinar for busy public health people who want to know whether behavioural sciences can do anything for them.
Register today for a webinar to be held at 11am-noon on 27th April. This webinar will provide busy Public Health Specialists a route map to understand the breadth of behavioural sciences and how they can be applied in public health, to help increase impact of your plans and strategies. You’ll also hear about the forthcoming national framework for behavioural sciences in Public Health.
Information on joining instructions will be circulated to registered attendees in due course.
Click here to join
The Webinar is now open for registration . Co-led by PHE, ADPH and HPPHN. 27th April. Register here
In 2014 the Chief Medical Officer Dame Sally Davies and others published a paper in The Lancet which argued we need a new wave in public health improvement – if the first was the improvements in life expectancy brought about by sanitary and water engineering, the fifth is cultural. Much debate has followed. I am convinced that the nature of our society is such that social, behavioural, environmental and cultural factors are very much part of the challenge we face in improving and protecting the health of the population. Which is why I believe behavioural and social sciences have an important contribution to make in Public Health.
Some promising starts but need more traction – a quick overview of 16 years’ work
This isn’t a new focus. There have been several attempts to do this before. The American Psychological Association produced a book on this 16 years ago, which is still a good read. A 2005 article also outlined some contributions from psychologists to Public Health. The US CDC produced an outline on its work as early as 2006. There were even special issues of the British Journal of Health Psychology in 1998 and the Journal of Health Psychology on the links between Public Health and Psychology.
More recently Professor Sir Michael Marmot asked the British Academy to produce a series of papers on the contribution of social sciences to Public Health. I was on the editorial group and co-wrote the introduction. I think it was a mixed start: some issues were addressed, many not. Much more remains to be done.
I could produce a bibliography and links list as long as my arm on how epidemiology and spatial criminology, public health and crime reduction, sociology and anthropology and lately operational research professionals have been publishing notable books and papers much more widely on their work around public health issues. I am planning a “rough guide” seminar on this. A webinar for public health people wanting a quick overview of how to navigate this whole world is coming in April 2017. (See the bottom of this blog for more details)
Incidentally, operational research methods – called the Science of better have both an affinity with and much value for Public Health at organizational level, so watch this space for another venture for public health in the next year. I’m also currently working on embedding some of these skills in my own organization through a programme where people who have graduated from our corporate leadership programme undertake a hybrid training programme combining public health skills like problem analysis, evidence-based practice and prioritization and operational research skills like problem structuring, problem analysis and modeling, to have a go at solving some of the challenges we face in the next few years.
Finally, several very useful and straightforward resources I would like to draw your attention to are those aimed at public health professionals by the BPS Division of Health Psychology.
The growing system role and appetite in government
Public Health England has been taking more of a system role in this with some great work shown at their conferences. Amanda Bunten (as of yesterday Dr Amanda Bunten!) one of the PHE team was profiled in The Psychologist with a piece which is great reading for anyone who wonders what a psychologist can do in public health. The work of my own colleague, Michelle Constable, was showcased with that or other local authorities in a recent Local Government Association (LGA) publication on behavioural insights for health used in local government.
But despite this and many other examples I could mention, those of us who have been advocating the stronger integration between the behavioural and social sciences and public health seem to be struggling to get much traction beyond some great work on behavior change, with places like FUSE, and the Cambridge and UCL centres being but a few I single out among many.
The Academy of Medical Sciences report on the health of the population in 2040 applies, in my view, just as much to the need for social and behavioural sciences to work on this area as biomedical sciences. Social Sciences will shortly launch its own report on the Health of the People. I for one see this as adding further impetus to the need to develop this work.
Public Health England have good reason to tell us that government is now very open to the inclusion of social and behavioural science in public health and a range of other issues. And this can only be to the good. That means the rest of us – practitioners, researchers, academics and commissioners – have an opportunity to come together and identify a way of how we all go about doing this together.
The barriers to greater integration and use of social and behavioural sciences in public health remain. From the rich discussions people have given their time and energy to recently, some of those are cultural, some of those are about training those of us did or didn’t get about different professions (in some EU nations they are much better about breadth of foundation training than we are in the UK), but there are two big challenges for me.
The first is mindset – if you see Public Health as a science in its own right, it doesn’t necessarily follow that you are as open as you could be to the insights other sciences have to bring. But if you see public health as an integrating mindset which takes insights from a range of fields- epidemiology, sociology, psychology, law, biology, medicine, toxicology and so forth – and integrates them to improve and protect the health of the population – then openness to new insights becomes a critical priority not just an add on. That brings me to the second set. Even if you have that mindset, how do you learn? To an outsider, the social and behavioural sciences can look fiendishly complex and confusing, and if you have limited time, how do you navigate to insights, tools and perspectives that can help you in your task. The issue of language itself – what do we mean by social science, what do we mean by behavioural science? can put people off. I still remember from my postgraduate psychology training debates on the difference between social social psychology and psychological social psychology that left me thinking the finer debates of philosophical hermeneutics looked simple and non-contentious by comparison.
These are major practice , policy and training issues which we need to find solutions for. I think our efforts to integrate will continue to falter until we address these coherently.
The need to help policy, practice and research meet
This set of challenges were among the reasons I helped found along with colleagues the Health Psychology in Public Health Network. I kept having people saying to me there was a need where practitioners, researchers, academics and commissioners with an interest in this could get support and help. I was determined to make a contribution to addressing this. In three years we have provided a place where over 1,000 people from students and trainees to academics and policymakers have come together on LinkedIn and in full membership. We try to model the Public Health – Psychology integration. I have just finished an amazing three years as first chair. Dr Angel Chater, a health psychologist, has now taken over as Chair. We have even issued our first awards for research students integrating social/behavioural and public health perspectives in their research. I’m hoping a book will come.
Moving as a system: promising work
I think we are on the verge of a major step forward. Yesterday, 17th March 2017, around 50 people representing a wide variety of agencies and stakeholders convened for an initial conversation on what we could do; brought together by the Association of Directors of Public Health (ADPH) , Health Psychology in Public Health Network (HPPHN) and Public Health England. The aim was to articulate the need for a framework for this work, to make the most of how social and behavioural sciences and public health could work together.
A small group with Public Health England, HPPHN, ADPH, LGA, British Psychological Society and Faculty of Public Health had previously convened to discuss and agree the need for work, produce a short document arguing for this, and then convene the stakeholder conversation yesterday.
It has been exciting working alongside Dr Tim Chadborne and colleagues at Public Health England, with the HPPHN and ADPH folks on this. And yesterday we had people as diverse as local authorities, ESRC, British Psychological Society, LSE FUSE, NIHR, many universities Society of Social Medicine, NICE and many more in the room.
We shared a co-written prospectus for developing a national framework for the use of behavioural and social sciences in Public Health and we asked people for their views on whether this was a good idea. We asked them to identify priorities and challenges, and what we should do next. We packed all this into two hours of work. And the day went well, even if the technology kept failing us. We have some rich material to write up, prioritise and turn into a plan.
Suffice it to say that the most important things for me were the atmosphere of consensus and good will in the room, and the fact we got enthusiastic support that we needed to do this. A writing group is being convened with a small number of volunteers and we will start to build more partners into the conversation going forward.
The work is only starting, but I think everyone yesterday shared a willingness and a determination to work together. We’ll keep you posted.
April webinar Behavioural Sciences for Public Health: the rough guide for busy PH specialists | Registration now open | 27th April
PrEP for HIV rolled out nationally would, on the figures I have seen, cost less than the NHS spends on dandruff and paracetamol. Much, much less. But does that make it a good investment? The only way we will find out is through a proper, transparent and robust prioritization process.
The Court of Appeal ruling today means that will now need to happen. The Court has dismissed NHS England’s appeal. It upheld much of an earlier judgment which NHS appealed against. The full judgment needs studying but the effect of the ruling will be that NHS England needs to put PrEP through a fair, transparent and proper prioritization process.
NHS England immediate response
This has been met by a disappointingly grudging and obfuscating release from NHS England https://www.england.nhs.uk/2016/11/update-on-prep/
I’ve blogged elsewhere including in Local Government Chronicle that of course we understand NHS England has to prioritise, the point is it needs to do it fairly and transparently. The tactics over PrEP were distasteful, condemned by charities representing patient groups they tried to play off against one another and, unfortunately, has now cost an awful lot of taxpayers money to confirm what most of us first contended.
NHS England’s news release among other things said three things about the judgment, some of which miss the point:
“First, it establishes that NHS England has the ability but not the obligation to fund PReP.” Actually that’s been the contention of most of us all along. This is a redundant point.
“Second, it means that should we decide to do so, we would not be subject to legal challenge on these grounds from rival ‘candidates’ for specialised commissioning funding.” Indeed. but the contention of many of us is that NHS England needs to face this fair and square through a proper, transparent and methodologically robust prioritization process. Waving round threats about legal action from others isn’t going to let NHS England off the hook from doing this properly. And NHS England seems to be slow to learn that this is just what happened – NAT and LGA took legal action and NHS England lost. So the point of all this, surely, is prioritise properly and fairly. Otherwise we’ll end up back in court.
“Third, it overturns the High Court in helpfully clarifying that Parliament did not intend that the NHS was expected to fund local authorities’ public health responsibilities just because they have not done so.” This is entirely beside the point and is a tenuous reading of the judgment. The point is NHS England CAN , contrary to their argued position, commission prevention initiatives. They contended all along they couldn’t. Let’s not start re-writing the history of the case and its particulars now NHS England have lost.
Things to remember during the coming months
Throughout this and what comes next, we need to remember the following key points:
- NHS England are up against it financially. But so are local authorities. Working together, not resorting to legal action, is the way forward.
- As I said above, PrEP will cost much, much less than the NHS currently spends on Paracetamol, and dandrfuff! And it will, in cost-return terms, save more. It makes, on the face of it, economic sense.
- The bigger prize, and a prize the health economic literature is starting to address, is the effect of investing in PrEP to stop the epidemic and end new transmission in England effectively.
- Fair and equitable prioritization needs to be a key process in the future of health and social care. Time to start now.
The wider issues
Importantly, it is established that NHS England has preventive powers, including powers to prevent HIV and commission drugs like PrEP. This is a victory for good sense and a joined up health and care system, which should put prevention at its heart. This decision makes good sense
- for the taxpayer, because it enables an intervention that will save more than it costs to be commissioned
- for people, because we have another powerful tool in the armoury of HIV prevention
- for a strategy to end HIV transmission in England, which is now within our reach, but only if we work better together, and use PrEP as one of the many tools to achieve that
It’s time to draw a line under this and work together to deliver a joined up HIV and sexual health system, which is what the taxpayer has a right to expect. NHS England has said today:
“In the light of the Court ruling we will therefore now quickly take three actions. First, we will formally consider whether to fund PreP. Second, we will discuss with local authorities how NHS-funded PreP medication could be administered by the sexual health teams they commission. Third, we will immediately ask the drug manufacturer to reconsider its currently proposed excessively high pricing, and will also explore options for using generics. We expect to be able to update on these developments shortly”
That’s immensely welcome, on all fronts.
I think most of us realize times are tight. And NHS England is right that we need to prioritise. My point all along is that their chosen tactics were a poor way to do it. It’s time now for everyone to come to the table, work together, and set about fair prioritization.
Work still to be done?
The work of doing a proper, fair and thorough prioritization process now must begin. This will need to evaluate, fairly and transparently, all the data in favour of PrEP and all the data against, as well as date in favour of other contender interventions. And it will need to compare them, fairly, on a like for like basis.
Having been involved in health care prioritization for many years, up to and including judicial review, the real work starts now. What has happened hitherto has been a tactical game.
It may be the decision is still to prioritise something else, but a few of us are coming together to make sure we subject the NHS process to as much scrutiny as we can possibly give it. The health economics appraisal, the statistical appraisal, the comparative cost-benefit appraisal and the process of decision making will all now be subjected to intense scrutiny. NHS England played the game of “we’ve had legal advice we cant commission this” then played the game of “other candidates might sue us”.
The only safe way forward is a methodologically robust, transparent, equitable and fair prioritization process.
I, and many others, will be watching this with intense interest.
In October, Public Health England produced its national guidance and I was privileged to be quoted in it. https://www.gov.uk/government/publications/suicide-prevention-developing-a-local-action-plan . The personal and the professional intermingled in what I said.
Tomorrow (November 9th) we will be hosting our local suicide prevention summit in Hertfordshire. Over 80 people will convene, from a range of backgrounds and concerns, to discuss and shape our future work on reducing suicides locally.
People who have been bereaved, people who have survived attempts at suicide, clinicians, agencies with concerns from transport to NHS and elected members will come together for what will prove an intense and important morning. I will stay for as long as I can before then going to present papers to our Cabinet.
I have in mind right now the inspiration of our Cabinet Member, and my colleagues who have organized and are leading this. Their leadership is writ large throughout this. For me this is an area where elected member drive, public health technical skills and community leaders like the folk behind Hector’s House, Ollie Foundation, SOBS and the MindEd Trust can come together despite austerity to look at the possible.
Since that guidance was published I’ve had a few colleagues in other areas say how they find this area challenging because of previous experiences in their lives. I can relate to that. I find this time of year emotional and this subject bittersweet to the memory. But I think that can be a good and energizing thing. For me, I can’t separate the personal and the professional in this. Though that does mean I need to be very conscious that my experience is not that of others, nor is it privileged or special. It’s just mine.
Suicide prevention for me is personal as well as professional. I’m not going to begin to try to get away from that. I find that this orients me in this whole process. It also helpfully reminds me that I’m not special, and am here to try to serve. Doing that in a world with no money is going to be interesting but I am going to try. We have nothing to fear from allowing the personal to inform, elucidate, energise and challenge the professional.
I sit here with the enduring memory of those in my life I have lost and, thank God, those I have not lost despite attempts, to suicide.
A best friend since I was young (I wrote about him in my quote in the PHE guidance) for starters. Then another great friend, D at whose bedside I, his partner and family spent too long watching him die in discomfort and pain. He was a man talented and infuriating in equal measures. who made an attempt to take his life – no we never did work out whether he really was serious and neither did the Coroner – changed his mind, seemingly recovered and then later just collapsed. He’d made a kind of half-hearted attempt at cutting into his veins. Being him he’d used a very small mother of pearl handled fruit knife.
By the time he collapsed the organ and system damage done by what seems a simple over the counter drug rendered it too late for any of us to save him. We could only hold, weep and watch in powerless frustration. It all felt clumsy. I felt clumsy. Even his funeral – at which I officiated at his request – I felt I didn’t get right. He and his parents wanted us all to clash and be garish. So I found a YELLOW shirt, a PURPLE tie and put the two together. Great. The shop assistant must have though we’d taken leave of any sense of taste. Unfortunately the suit I wore, not quite thinking, turned the whole lot into something muted and nearly not dreadful. (It was 1998, come on!)
Even the F…ing crematorium played the wrong piece of music at the wrong time despite three practices, and when I pressed the button for the lights to go down, the curtains to come round and me to read the committal, naff all happened. And then when we scattered his ashes his partner dropped the urn. On my foot.
D’s mother said after the funeral that she felt very proud afterwards of saying “bum” in a church during her elegy. I was too busy trying to get C, one of D’s mates to get through his poem without choking in tears at the time to notice and realizing someone had nicked the matches I had placed very carefully for the candle lighting in memory. So I even missed that. Then one day I realized D would have found this all absolutely hilarious. And I laughed through my tears.
A third friend, A, got into drugs and couldn’t cope. He’s now got a degree and is a social worker. Another, S, just couldn’t handle what was going on for the people he loved. A long night with charcoal drinks and vomit bowls in a tatty corridor in a hospital in Southern England followed after I found him and took him to A and E. Thankfully, he’s now sorted and thriving. Don’t think he ever forgave me for joining forces with the nurses though.
Unsurprisingly, as I get to doing my introduction to this event, tomorrow, a range of things are going through my mind.
November is always a time of emotion for me. November for Catholics is the month when we remember, grieve for and celebrate our dead. For starters we write a great long list of folk we’ve lost and remember them before God every day of the month. Among other customs which must look odd to the rest of the universe. For Catholics All Saints Day is immediately followed by All Souls day. The community of faith consists of the living and the dead, and they are all to be cherished. There was a time when I found this tradition silly, awkward, embarrassing. I now realize just how valuable it is because it reminds me of those who shaped me for who I am.
Last week I took part in the launch of a website called the Art of Dying Well, a conversation and tool to help those at the end of life and those who love them. I’m one of the stories on the site (my brush with death and what it has given my life. I’m the only person on the site who swears while telling their story. D’s mum would be proud!)
This week I’m at a suicide prevention event. Two weeks from now we will hurtle into World AIDS Day and the AIDS memorial quilt will be at the World AIDS Day Mass, where I will call to mind friends whose lives have taught me much and who I have lost. On 4th December up comes the anniversary of my diagnosis with cancer. Could you believe looking back that this is an energizing and happy time? But it is.
One of the amazing things about this job is that I sometimes find myself in the middle of chains of events like this month and have to remind myself what’s going on. And what’s going on here is about cherishing life, with the personal and the professional informing each other.
How does one hold all this without contradiction? Well, what I am trying to say here is that this all actually makes sense to me. Not terribly sure I really can explain it much better than that. And that means being open to the emotion that’s a part of it. I can no more avoid the emotion of all this than I can fly. Because it’s all too much a part of me. And because it keeps me real, and hopefully not wooden. I can’t do public health without emotion. I think I’m better for it. Whether that helps you I don’t know. But it works for me. Being professional does not mean quarantine for one’s emotions. It means acknowledging them and their impact.
Tomorrow I will have the immense privilege of being with those who despite their bereavement and grief are taking part in a collective exercise to save and cherish life. I know from my own experiences that getting to that place is bloody tough.
I believe in reducing and preventing suicide because the dignity and preciousness of each person means we should seek to prevent suicide wherever possible.
We may have a low suicide rate here, but that doesn’t mean we shouldn’t try to reduce it as much as we feasibly can. So for as long as I’m in the room tomorrow, I’m up for the conversation. Because I will be in a room full of people I admire beyond words.