Case study

Use of health economics tools by Shropshire Public Health

Local authority use of the PHE prioritisation framework to help rank public health programmes.

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Summary

The Shropshire public health team used the Public Health England (PHE) Prioritisation Framework (PF) to evaluate the potential impact of its public health programmes and to assess its priority health programme areas. They found the framework to be a logical, helpful process for aligning scoring criteria to both public health and Shropshire Local Authority priorities which is helpful for communicating commissioning intentions and value of services to senior decision makers, elected members and wider partners. The process has also been beneficial for promoting discussion and sharing learning to explore possible future collaborative opportunities for joint commissioning. We would recommend that if repeated, wider partners from across the local health and social care system should be involved in using the framework to set shared objectives prior to any discussions about reductions or changes to budgets.

Background

The Shropshire public health team wished to identify evidence-based spending decisions across its priority public health programmes funded by the public health grant and for each programme identify evidence relating to its current levels of investment compared to its outcomes.

What was involved?

Shropshire Public Health has the following priority health programme areas:

  • social prescribing
  • MSK and falls
  • type 2 diabetes prevention
  • 0 to 25 years public health nursing and health visiting
  • substance misuse
  • sexual health
  • NHS health checks
  • mental health and wellbeing
  • tobacco control

Each of these priority areas was first assessed against Shropshire’s first and second level criteria for public health:

  • support asset based community development
    • strengthen communities
    • volunteer and peer roles
    • access to community resources
  • help people live long, happy productive lives and improve population health and wellbeing
    • social and emotional health improvement
    • physical health improvement
  • health inequalities (including older people, geographic location, deprivation, looked after children, homelessness)
    • improve access
    • health inequalities (including older people, geographic location, deprivation, looked after children, homelessness)
  • join up services and reduce health and social care demand
    • cost effectiveness and ROI
    • reduce demand for health and social care services
    • political acceptance

For each programme area, the level of investment was identified, the outcomes determined and the feasibility for change.

A resulting dashboard indicated that the programme areas with the highest potential for achieving the above criteria were:

  • NHS Health Checks
  • 0 to 25 year service
  • substance misuse
  • tobacco control

The toolkit provided a summary dashboard for recording discussion on changes in the direction of spending and to model different scenario plans in order to adjust allocated budgets to each of the programme areas and model the difference in value added (value is based on likelihood to deliver against the identified criteria).

However, it was decided against solely using the outcomes from the toolkit to make these directions of spending suggestions or make recommendations about the best use of resources, due to the uncertainty over the next few years of local financial sustainability.

The team recognised that it would be essential for wider partners to be included within discussions, prior to any decision being made on adjusting budgets, given the potential impact on their services and how programmes may be delivered in the future.

It was therefore agreed that although the tool could be very helpful for planning in a more economically stable environment, it did not answer some of the local challenges (such as the options of exploring joint commissioning opportunities with other services).

Shropshire Public Health concluded that this type of systematic approach in an organisation could be useful (particularly if wider partners are involved from the early stages) but it is essential that it would be followed through and used continually.

What worked well?

The Shropshire Public Health team found that the Prioritisation Framework:

  • has a logical structure
  • has clear instructions that anyone can pick up and follow the process
  • other than coordination and instruction, the amount of time required to manage the process and complete the framework is not too onerous
  • has the ability to record every aspect of project management in one comprehensive document. It was helpful in promoting conversations between programme leads to consider shared cross-programme objectives for future commissioning opportunities
  • was effective when thinking about the assessment criteria for Shropshire’s public health ambitions and vision
  • encouraged going back to the evidence base to understand the process of where we have got to now
  • promoted conversations on topics that may not have been previously considered, for example, the political acceptance for statutory services following the loss of the public health grant and how best to frame the impact of their programmes in a political cycle
  • has filled a gap for those who have not been involved with this type of business planning before and emphasises the key factors to communicate the importance of doing these particular programmes

What could be improved?

The preparatory work for programme leads and their teams to complete the process is time consuming, so teams would not want to do it too often and would need to plan time accordingly in advance.

In addition:

  • the process should be undertaken with wider (non public health) services and partners from the outset, to maximise the opportunity of achieving shared objectives and promote discussion of how programmes could be jointly commissioned
  • it can be difficult to record evidence in the PF unless it is text-heavy and it is unsuitable for different formats such as tables and lists. Recording evidence in separate documents requires a link to the framework.
  • the framework is more focused on services and is not able to measure the value of contribution from people in teams, volunteers, or from mobilising community assets
  • the process lends itself to measuring traditional public health programmes such as smoking cessation or NHS Health Checks, which have clearly defined outcomes and activities to measure
  • comparing programmes with other local authorities can be difficult as there may be significant variation as to what is being provided, for example, in terms of target population, different complexities of client needs
  • many public health programmes rely on wider services and infrastructures, so if there are difficulties with referral pathways, relationships with partner organisations or NHS disinvestment in related services which impact outcomes

Next steps

There is a need to demonstrate that other parts of the council (and other partners) have some ownership of the role they play in promoting public health. It needs to be part of everyone’s business case, planning application and policy development across the local authority.

A question for PHE to consider is whether they could help to quantify the added value of public health work, intelligence and analysis to other local authority activity.

Further information

Gordon Kochane, Consultant in Public Health, Shropshire Council.

Published 27 July 2018