Are thinking and doing on prevention going in opposite directions?

It’s obvious that I am persuaded by systems approaches to health and social care, and public health in particular.  The level of complexity in most systems means that univariate explanations of most health outcomes and behaviours, let alone services, just do not cut it for me.

That’s why I am partly encouraged and partly dismayed at two national proposals, and at the way the evaluation of the Family Nurse Partnership seems to have been responded to in various places.

First, this week; the changes to community pharmacy.

The proposal that we need more pharmacies in care homes and GP surgeries is good, but I’m dismayed that a) the proposals seem to involve closing large numbers of pharmacies and b) we are still no closer to seizing the significant opportunities pharmacies present to our current challenged system. The thinking on this seems to me to be either poorly communicated or worryingly poorly formed. More online pharmacy could bring benefits, but there are risks: in the sexual health field guidelines have already needed to be reinforced because for some conditions online prescribing and sub-optimal prescribing by GPs seems to be bringing about more antibiotic resistance and with it greater risk and cost. . Despite this, at least two  major UK online pharmacies are still offering tablets, with what amounts to the frankly appalling disclaimer that “the best treatment is an injection but if you cant get that we will still sell you tablets, despite what the Chief Medical Officer says.”

Pharmacies, for me, remain one of the biggest infrastructures for secondary prevention and disease management in long term conditions we don’t use.  And for no convincing reason. Moreover, a recent review of the evidence on minor ailment schemes my team undertook convinces me that the potential role of pharmacies in alleviating the problems of a straining system are significant. This is about channel shift – shifting money to shift patient flow. Why does it feel that every other major customer facing system in the UK is at least trying this at scale and pace except primary care? Not only are we failing to seize these opportunities, we seem to be acting under the new proposals in a way that could damage our ability to.  Where is the joined up thinking here on cost and outcome across the system?

Secondly, the National Diabetes Prevention Programme. It’s brilliant that we want to do this in England, and it’s much needed given what is a dramatic increase in type 2 diabetes. But it is being rolled out in a way which seems to be at risk of taking an entirely conformist approach to intervention fidelity with the lifestyle intervention which comes as part of it.  Eugene Milne in his editorial in the Journal of Public Health warns us that the lesson from the Family Nurse Partnership in the UK was that pursuing intervention fidelity at the expense of flexibility and local systems may backfire.

Thirdly, the evaluation of the Family Nurse Partnership landed for some like a bombshell. It shows little benefit over usual care and is not cost effective, said the evaluation. It shows a  whole host of other benefits and is value for money, say others (especially FNP themselves). But the shock of an intervention with what seemed like loads of evidence essentially not doing what it claimed on the tin (despite doing other things) was palpable. If this teaches us anything, it’s that we need to think carefully about the system and infrastructure of services already in existence before spending huge sums of money on an intervention from an entirely differently constructed health system, even if the evidence seems cast iron. What do we do now? My advice is do some thinking across all commissioners about the best use for that money, with some careful reading of the entire evaluation report and evidence.

We need to apply the lessons here to the coming National Diabetes Prevention Programme and other programmes. What will be the impact of using or not using the biggest potential prevention infrastructure on our doorstep – the physical activity offer of local government? Local authority physical activity infrastructure remains the biggest under-utilised asset to a prevention focused NHS we have. The newly released Kings Fund report for the District Councils’ Network reinforces that point.  Getting every patient into regular physical activity is an essential for primary, secondary and tertiary prevention. The Academy of Medical Royal Colleges report gave us all the evidence we need for this.

As I have said elsewhere, pumping ever more money into the NHS without major re-think of how we do health more preventively is neither a sustainable nor an effective solution for the 21st Century.

In the midst of this, two reports this week give us some cause for hope, if we but choose to learn from them. The first is the Kings Fund report I mentioned earlier on what District Councils can do for health and social care systems. The second is the report by NHS Clinical Commissioners on just some of the things the NHS can do to be prevention focused.  Every commissioner could benefit by reading and applying these two reports.

A convincing, coherent narrative for Prevention

Part of the problem these examples illustrate is that we still don’t have a coherent narrative for what prevention needs to do across our complex systems which works for the crisis of demand and disease we are now in.

I have been banging on now for some time about the need for us to create a more coherent narrative on prevention.

A narrative on public health which is based primarily on primary prevention (i.e. stopping things happening in the first place) is not going to work for us when we have an epidemiological crisis (lots of people with disease developing costly and often avoidable additional disease and disability) turning into a system crisis (significant additional demand for services and technologies to deal with the epidemiological crisis) in the middle of a financial crisis (massive cuts to local government and the NHS perennially in financial crisis because of the epidemiological crisis.)

We now have tens of thousands of people with established disease for whom secondary prevention (for example reversing harm, preventing worsening, preventing disability) and tertiary prevention (for example minimising harm and disability, preventing death) is now a major fiscal and system challenge. And one we still have to do a lot better to rise to. We need a prevention narrative that works for our population now.

It feels like the perfect storm. And it looks like the one Wanless predicted we would be in if we didn’t start doing things differently.

I’ve been using a “layers and phases” approach to public health in Hertfordshire, I believe with some success if you look at some of our outcomes, for over three years now. The essence of this is that to get health outcomes in something as complex as a social system you need to understand the layer of intervention (from biological to socio-political) and the phasing of it (from short term to long term.) I explain where this thinking was in chapter three of our public health strategy.

But I know that this narrative isn’t enough.

Prevention will be a key focus of our Health and wellbeing Strategy refresh underway now, and our new public health strategy will seek to major on this, as much as we can in a world where government cuts to public health feel like they’re ripping up the public health floor of a shed to repair its NHS roof. And Social Care will end up paying the bill in avoidable demand from avoidable disability and social care need if we fail. So the challenge is on to articulate the must-dos and can-dos.

Articulating a narrative for prevention today

I’m going to put my money where my mouth is in early March and lead one of the joint University of Herts – Herts Public Health masterclasses, this time on prevention, specifically to try to articulate a system wide narrative on prevention for the current crisis. I shall probably fail. But I want to start a conversation on what prevention looks like in this complex world.

The biggest challenge is not concept but paucity of evidence on secondary and tertiary prevention.  It’s not a “sexy” area to research and it doesn’t feature as a major priority in research funding consistently anyway. Yet we need to find more and better ways of keeping the significant numbers of people who already have disease from eating up more and more time and money.  This is the territory we need to be in.

Intellectual and evidential needs for a complex world

We need theory that takes into account complexity at layers of existence and social life, and across time.  We need research that gets to grips with complexity. We need methodological and philosophical imagination that seeks to articulate what can be done, the systems thinking to implement it alongside the research methods to evaluate it.

Are we really prepared for this?  Some of the thinking on display at present seems astonishingly single-track in its conceptualisation of problems and evidence. Take just four trite nostrums we’re hearing, and I appreciate these are sometimes the extreme end but we are hearing them:

  • E cigarettes lead to renormalisation of smoking and are a gateway to it (Feel to me like this is mediocre science pressganged into the service of oft-discredited gateway theories which are more expressions of assumption and fear than based on any strong evidence)
  • Sugar is our biggest public health problem and the sugar tax will solve obesity (a flagrant overstatement of the evidence and a victory for single track thinking over the much more complex reality)
  • Prevention will solve all our financial problems (not if we cant articulate what we need to do and how we’ll do it, it won’t)
  • We must have minimum unit pricing on alcohol and the modelled evidence for it is convincing but health checks are a waste of money because the evidence for it is modelled (inconsistent approaches to the same level of evidence based more on worldview and rhetoric than the quality of evidence per se.)

The difficult balance between extrapolation and speculation

The philosopher Mary Midgley in criticism of scientists who go way beyond where evidence or decent theory would allow in their conclusions talks of “rhetorical attempts to turn science into a comprehensive ideology” (the myths we live by, pages 26-30)and reminds us of the need to avoid leaps of fancy which sit too comfortably with a simplistic view of how we feel the world ought to work. There often feels too much of this around.

But at the same time we need imagination and its potential solutions. So what do we do? We seem to be caught in a double bind. The desire to reduce disease, disability and death (and the spiralling cost) but the paucity of the evidence to support it in some areas.

Short termism, lack of systems thinking and focusing on “magic bullets” are diseases which have bedevilled British policy thinking on some areas including prevention.

Now more than ever is the time for clear and rigorous thinking about complexity. So where do we go?

Well, there are some principles for me, laid out below. They are all about finding a”fit” between aspiration for better health, evidence, theory and reality. One could call this a conceptual quadrilateral : reason, reality, evidence and theory all brought into play. (And yes, I nicked the idea of the quadrilateral from Thomas Aquinas and Charles Wesley.)

  1. In a world where evidence seems silent we have to generate hypotheses from theory and test them. Good scientific method is still relevant and we extrapolate from what evidence we have, testing for real-world fit.
  2. We then locate our problem in our complex social system, modelling that system as best we can
  3. We triangulate what we know from other fields of study to nuance and refine this
  4. We look at where we should intervene and the potential effects across the system
  5. We re-test it for congruence with the real world
  6. We develop policy proposals which take this into account,
  7. We roll-out test, evaluate  and based on outcomes refine or re-think

A lot of work, I hear you say, and these principles themselves need refinement. Well, our current approach doesn’t seem to be working. Can you suggest a better way?  Mary Midgley would say reductionist explanations fail to reflect complex reality.

Systems theory is, of course, a theory. Over-reliance on that carries the same dangers I warn of above. But it seems to have “fit” so far and if not taken too uncritically can help us out of reductionist prevention narratives.

One of the successes of the Marmot Review is that it took complexity into account when formulating its policy solutions. It avoided reductionism while giving some clear priorities. It wasn’t overly systems focused, but as a means of synthesising complexity into policy priorities it’s a useful example.

“Fit”: the example of Sugar

Let’s try this out on sugar: the evidence on sugar is nuanced. The sugar tax when it is advocated by some as the single biggest public health magic bullet is a narrative that is as ill-conceived, dangerous and doomed to failure as it is simplistic. What the evidence from a range of fields (economics, epidemiology, sociology) suggests is that a range of issues need to be tackled from food formulation to food access, food culture, food marketing, and more besides.   Totemising sugar tax as a single measure of whether a government is public health oriented is just plain wrong.  Mary midgley would call this ideologizing rather than looking to layers of explanation.  If history shows anything, it shows that it will backfire on us.

The careful review of evidence in the PHE review  that a sugar tax could be one measure in tandem with others does not support some of what frankly seems to be flights of advocacy fantasy some public health commentators are engaging in on this issue.

A sugar tax plus other measures may play their part. But what about the reinstatement of a public health duty on schools to ensure the best health of children during the school day? (As we know, healthier students have higher educational attainment.) What if it had teeth and was taken seriously by OFSTED?  That might actually do a lot, if well conceived. But you’d still have to tackle the rest of the social system the child grows up in – so reinforcing the point that no single intervention is enough.   A manifold of thought-through measures together which value good health might be.

We await the government’s obesity strategy.  I for one hope it provides us an opportunity to marry its proposals with other action at local and national level to deliver some joined up systems thinking and action on Obesity. If we don’t do this, we can look forward to an ever-increasing diabetes and disability spiral which the NHS and Social Care will need ever more money to cope with.  If all we get is a sugar tax, we can assume failure once again. And the saddest thing is it will be an entirely avoidable failure of thinking which continues an entirely avoidable rise in disease.

Public Health competencies: some friends for a new age

If we have learned anything in Public Health surely it is that it is almost never a one solution issue in the complex challenges of today. Dominic Harrison, the DPH for Blackburn with Darwen, famously said that we in Public Health work to a definition of health coined in the 1940s, a suite of competencies set in the 1970s and call ourselves change agents for the 21st Century. Our curriculum needs an overhaul.  And the five things we need in it for today are 1) Philosophy of Science, 2) Behavioural Sciences, 3) Complexity Analysis Tools, 4) Policy Analysis and Influencing skills and 5) Methodological and research skills for the complex real world.

Prevention in the real world is a challenge and an opportunity for public health. Now more than ever is the time for that careful re-engagement of our best analysis with the problems of a health and social care system no longer coping.




A whole system approach for Mental Health?

Good Mental health is an issue, or set of isues at once both fundamental to our lives and diffuse in the factors which influence it, that it seems a perfect candidate to take a system wide approach to it, from our work/study places to our homes and social environments.  Systems approaches in public health have been a key feature of our public health strategy in Hertfordshire so far.  Chapter three of our strategy outlines our conceptualisation of some of this at the time, though it’s fair to say we have moved on in some of this.

Trying to build a whole systems approach in Hertfordshire

We’re building a systems approach to Mental Health at population level in Hertfordshire, and this week we took a look at what we have already done:

  1. A major Needs Assessment exercise led by Professor Jonathan Campion
  2. A major transformation of adult drug and alcohol services
  3. investment into Child and Adolescent Mental Health Services and a trasnformation programme to reshape services, following the whole system review
  4. A similar transformation programme just kicking off on drugs and alcohols services for children and young people
  5. A resilience programme in Schools already underway and more work planned
  6. A mental health crisis care concordat with a range of projects under it to improve crisis care
  7. A review to ensure that people with drug or alcohol problems and mental health issues spend less time with police under place of safety orders
  8. A pilot programme for very complex adults
  9. A veterans programme
  10. A suicide reduction programme
  11. A workplace mental health programme run by Business in the Community
  12. Significant increase in uptake of IAPT (psychological therapies)
  13. Developing an approach to recovery – a recovery college
  14. A significant investment in anti-bullying work which has seen us win multiple awards.

All of these are areas of work still underway, and we have much to do still, but a large coalition of agencies in Hertfordshire is working on this. Statutory, commercial, third sector and academic.

Year of Mental Health : Building Leadership

We are in the middle of a Year of Mental Health, which ends in July 2016. The whole purpose of which is to create some focus around this work, to reduce stigma around mental health and to build some political leadership.

We signed up to the local government mental health challenge.

The County Council has two elected member champions, each District Council has an elected member champion, and we have one MP signed up as a Champion. We are now starting work on parish and town councils.

We have more work to do, obviously, and during this year we will do much more on a number of these.

We have significant Leadership on this issue from our Mental Health Trust and University. But this is not an issue which can be left to them. So building leadership across the system is a task we are all focusing on. I think we’re moving on this.

Work still to be done

There are a range of pieces of work to be done and one of the pieces of work we will be doing this year. Working with the Providers, we will be developing a strategy to improve the physical health of people with mental health problems. We are already working on reducing smoking in this population, and have also made some progress with physical health with people with learning disabilities.

We will also be working mental health more strongly into service specifications for health visiting and school nursing.

Thinking started by our Public Health Conference December 2015

Our rationale for doing all of this is that there is strong evidence that doing it will improve health outcomes and good evidence that it will reduce cost to the public purse.

One of the presentations of the day which got people thinking was looking at a system wide approach to mental health, i.e. taking a population or public health approach to mental wellbeing and mental ill-health. Andy Bell from the Centre for Mental Health took us through this and gave us prolific advice. I took from my notes of Andy’s session what essentially, with one or two additions from me amount to a 16 point plan, which together forms the basis of a manifesto for population mental health. I’ve augmented this a little with some evidence to back up what Andy was saying. What got me excited about this was that this is one of the most comprehensive and straightforward cross-system manifestos I have ever seen for preventing and reducing mental ill-health in a population.

Andy also gets what I call the overlapping venn diagram of the big population tasks for ensuring we keep people in good mental health . I’ve suggested this in a diagram below. You can add to this the fourth big task of helping people experiencing mental ill health to recover, build resilience wherever possible and get back to the best state of wellbeing they can. Together the sixteen tasks below add up to a manifesto across these four big tasks of population mental health.

mental health diagram

The four big tasks of population mental health

It’s always helpful when working on system issues to get a clear conceptualisation of these. One of the problems with mental health is this can be difficult. So we’ve been testing out since December the four big tasks, which provisionally we have down as below. We may change them but welcome input and comment.

  1. Promoting wellbeing – a good and positive state
  2. Promoting psychosocial resilience – giving people skills to cope with stressors and life
  3. Preventing ill-health – spotting signs, intervening early with basic interventions
  4. Addressing and recovering from mental ill-health – the emphasis on best possible coping, functioning and recovery


The System Must Dos to get good outcomes for good population mental health

I’ve slightly amended my earlier list and now, below, have 18 system must dos which I hope to be working with Andy Bell at Centre for Mental Health and colleagues on. I’ve put these as a lifecourse approach, which should help us put them into our Health and Wellbeing Strategy and also develop a population mental health programme. I’ve also adjusted these so that they each track to one or more outcomes from our Needs Assessment.

  1. Invest in good parenting – reducing the cost of conduct disorder and other problems in later life
  2. Maternal Mental Health during and after pregnancy, including quick access to cognitive behavioural therapy as a priority
  3. Ensuring the key role of schools in mental health is delivered
  4. Primary School is key, and the first major external influence on childrens’ resilience
  5. The whole school approach is the most effective thing you can do
  6. Ensure good adult resilience and early intervention
  7. Workplace interventions pay off – the positive and supportive psychosocial working environment is a key part of this
  8. Early identification
  9. Reducing loneliness – a big task for resilience as well as recovery
  10. Address alcohol issues especially where it’s used for self-medication. You could do the same on drugs and tobaco
  11. Zero suicide – we have to be ambitious
  12. Relapse Prevention especially for psychosis
  13. Support Recovery , always and in every service
  14. Ensure you address physical and mental health –cardiovascular health, smoking, weight and other physical health issues are disproportionately seen in people with mental ill-health. We must address these because they reduce life expectancy, worsen burden of disease and disability and are important in getting people to better mental health
  15. Identify and address unmet need, especially in people with long term conditions
  16. Liaison Psychiatry in every Hospital
  17. Smoking – get people off tobacco,
  18. Make it happen using a system public health approach
  19. Reduce stigma and increase awareness

Systems within Systems

You can articulate systems within systems on this. (Lets not get hung up on semantics or become systems theory nerds, the point is its means to help us change the health of our population for the better, not become experts debating macro, meso and mico system architectures), so within Schools the evidence would point us, Andy Bell suggested, to some issues within the school as a system:

  • Target young people at the greatest risk for mental ill health and reducing resilience. The Good news here is there are lots of interventions which demonstrate value for money
  • Adolescence – ensure good resilience here especially because there is mounting evidence of worsening wellbeing among girls. Involve young people in service design and re-design.
  • Target young people involved in gangs and crime to provide safe and credible routes out and into support. This will pay off later


The System Critical Succes Factors

My reading and working on these issues convinces me that in addition to these must dos within the system itself, there are a number of critical issues which help determine success or failure in getting a systems approach to mental health. I call these Critical Success Factors.  They change, in my experience, depending on your system or the issue you are dealing with. But here, for the most part, are the ones I find which commonly emerge:

  1. A clear shared view of the system
  2. Ability to focus up and down from system to particular issues
  3. Leadership across the system
  4. Understand need using data and peoples knowledge
  5. Set outcomes
  6. Identify and prioritise interventions
  7. A balanced scorecard approach to this
  8. Multiple actors, multiple partnerships, shared vision – a programme approach
  9. Evaluate and iterate

We’ll continue this work, and I hope to write this up in more detail. But having been at this now for around two years, three years for some pieces of work, I believe there are signs we are moving. The issue will be, if the system is complex, how on earth do we evaluate it?  Another blog….