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. http://www.pharmaceutical-journal.com/news-and-analysis/news/government-outlines-plans-for-community-pharmacy-in-england-following-cuts-announcement/20200591.article
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. http://www.bhiva.org/documents/News/151218/DH-CMO-CPO-letter.pdf . 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. http://jpubhealth.oxfordjournals.org/content/37/4/561.full.pdf+html
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.http://www.kingsfund.org.uk/audio-video/district-councils-contribution-public-health 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. http://www.aomrc.org.uk/general-news/exercise-the-miracle-cure.html
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. http://www.nhscc.org/latest-news/delivering-a-healthier-future/ 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. http://webarchive.nationalarchives.gov.uk/+/http:/www.hm-treasury.gov.uk/media/D/3/Wanless04_summary.pdf
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. http://www.hertsdirect.org/docs/pdf/p/phstrat.pdf
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.)
- 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.
- We then locate our problem in our complex social system, modelling that system as best we can
- We triangulate what we know from other fields of study to nuance and refine this
- We look at where we should intervene and the potential effects across the system
- We re-test it for congruence with the real world
- We develop policy proposals which take this into account,
- 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 https://www.gov.uk/government/publications/sugar-reduction-from-evidence-into-action 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.