Institutionalising preventive health: what are the key issues for Public Health England?

Professor Paul Cairney, University of Stirling

Dr John Boswell, University of Southampton

Richard Gleave, Deputy Chief Executive and Chief Operating Officer, Public Health England

Dr Kathryn Oliver, London School of Hygiene and Tropical Medicine

The Green Paper on preventing ill health was published earlier this week, and many have criticised that proposals do not go far enough. Our guest blog explores some of the challenges that Public Health England face in providing evidence-informed advice. Read on to discover the reflections from a recent workshop on using evidence to influence local and national strategy and their implications for academic engagement with policymakers.

On the 12th June, at the invitation of Richard Gleave, Professor Paul Cairney and Dr John Boswell led a discussion on ‘institutionalising’ preventive health with senior members of Public Health England (PHE).

It follows a similar event in Scotland, to inform the development of Public Health Scotland, and the PHE event enjoyed contributions from key members of NHS Health Scotland.

Cairney and Boswell drew on their published work – co-authored with Dr Kathryn Oliver and Dr Emily St Denny (University of Stirling) – to examine the role of evidence in policy and the lessons from comparable experiences in other public health agencies (in England, New Zealand and Australia).

This post summarises their presentation and reflections from the workshop (gathered using the Chatham House rule).

The Academic Argument

Governments face two major issues when they try to improve population health and reduce health inequalities:

  1. Should they ‘mainstream’ policies – to help prevent ill health and reduce health inequalities – across government and/ or maintain a dedicated government agency?
  2. Should an agency ‘speak truth to power’ and seek a high profile to set the policy agenda?

Our research provides three messages to inform policy and practice:

  1. When governments have tried to mainstream ‘preventive’ policies, they have always struggled to explain what prevention means and reform services to make them more preventive than reactive.
  2. Public health agencies could set a clearer and more ambitious policy agenda. However, successful agencies keep a low profile and make realistic demands for policy change. In the short term, they measure success according to their own survival and their ability to maintain the positive attention of policymakers.
  3. Advocates of policy change often describe ‘evidence based policy’ as the answer. However, a comparison between (a) specific tobacco policy change and (b) very general prevention policy shows that the latter’s ambiguity hinders the use of evidence for policy. Governments use three different models of evidence-informed policy. These models are internally consistent but they draw on assumptions and practices that are difficult to mix and match. Effective evidence use requires clear aims driven by political choice.

Overall, they warn against treating any response – (a) the idiom ‘prevention is better than cure’, (b) setting up a public health agency, or (c) seeking ‘evidence based policy’ – as a magic bullet.

Major public health changes require policymakers to define their aims, and agencies to endure long enough to influence policy and encourage the consistent use of models of evidence-informed policy. To do so, they may need to act like prevention ninjas, operating quietly and out of the public spotlight, rather than seeking confrontation and speaking truth to power.

 

Image By Takver from Australia [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)], via Wikime

The Workshop Discussion

The workshop discussion highlighted an impressive level of agreement between the key messages of the presentation and the feedback from most members of the PHE audience.

One aspect of this agreement was predictable, since Boswell et al’s article describes PHE as a relative success story and bases its analysis of prevention ‘ninjas’ on interviews with PHE staff.

However, this strategy is subject to frequent criticism. PHE has to manage the way it communicates with multiple audiences, which is a challenge in itself.  One key audience is a public health profession in which most people see their role as to provoke public debate, shine a light on corporate practices (contributing to the ‘commercial determinants of health’), and criticise government inaction. In contrast, PHE often seeks to ensure that quick wins are not lost, must engage with a range of affected interests, and uses quiet diplomacy to help maintain productive relationships with senior policymakers. Four descriptions of this difference in outlook and practice stood out:

  1. Walking the line. Many PHE staff gauge how well they are doing in relation to the criticism they receive. Put crudely, they may be doing well politically if they are criticised equally by proponents of public health intervention and vocal opponents of the ‘nanny state’.
  2. Building and maintaining relationships. PHE staff recognise the benefit of following the rules of the game within government, which include not complaining too loudly in public if things do not go your way, expressing appreciation (or at least a recognition of policy progress) if they do, and being a team player with good interpersonal skills rather than simply an uncompromising advocate for a cause. This approach may be taken for granted by interest groups, but tricky for public health researchers who seek a sense of critical detachment from policymakers.
  3. Managing expectations. PHE staff recognise the need to prioritise their requirements from government. Phrases such as ‘health in all policies’ often suggest the need to identify a huge number of crucial, and connected, policy changes. However, a more politically feasible strategy is to identify a small number of discrete priorities on which to focus intensely.
  4. Linking national and local. PHE staff who work closely with local government, the local NHS, and other partners, described how they can find it challenging to link ‘place-based’ and ‘national policy area’ perspectives. Local politics are different from national politics, though equally important in implementation and practice.

There was also high agreement on how to understand the idea of ‘evidence based’ or ‘evidence informed’ policymaking (EBPM). Most aspects of EBPM are not really about ‘the evidence’. Policy studies often suggest that, to improve evidence use requires advocates to:

  • find out where the action is, and learn the rules and language of debate within key policymaking venues, and
  • engage routinely with policymakers, to help them understand their audience, build up trust based on an image of scientific credibility and personal reliability, and know when to exploit temporary opportunities to propose policy solutions.
  • To this we can add the importance of organisational morale and a common sense of purpose, to help PHE staff operate effectively while facing unusually high levels of external scrutiny and criticism. PHE staff are in the unusual position of being (a) part of the meetings with ministers and national leaders, and (b) active at the front-line with professionals and key publics.

In other words, political science-informed policy studies, and workshop discussions, highlighted the need for evidence advocates to accept that they are political actors seeking to win policy arguments, not objective scientists simply seeking the truth. Scientific evidence matters, but only if its advocates have the political skills to know how to communicate and when to act.

Although there was high agreement, there was also high recognition of the value of internal reflection and external challenge. In that context, one sobering point is that, although PHE may be relatively successful now (it has endured for some time), we know that government agencies are vulnerable to disinvestment and major reform. This vulnerability underpins the need for PHE staff to recognise political reality when they pursue evidence-informed policy change. Put bluntly, they often have to strike a balance between two competing pressures – being politically effective or insisting on occupying the moral high ground – rather than assuming that the latter always helps the former.

This blog post was originally published on the PolicyBristol blog.

How can researchers engage with policy?

Dr Alisha Davies

Dr Laura Howe

Prof Debbie Lawlor

Dr Lindsey Pike

Follow Alisha, Laura, Debbie and Lindsey on Twitter

Policy engagement is becoming more of a priority in academic life, as emphasis shifts from focusing purely on academic outputs to creating impact from research. Research impact is defined by UKRI as ‘the demonstrable contribution that excellent research makes to society and the economy’.

On 25 June 2019 the IEU held its first Engagers’ Lunch event, which focused on policy engagement. Joined by Dr Alisha Davies, Head of Research from Public Health Wales, Dr Laura Howe, Professor Debbie Lawlor and Dr Lindsey Pike from the IEU facilitated discussion drawing on their experiences – from both sides of the table – of connecting research and policy. Below we summarise advice from our speakers about engaging with policy.

The benefits of engaging with policy & how to do it

  • As an academic you need to consider what your ‘offer’ is. What expertise do you bring? This may be topic specific knowledge or relate to strong academic skills such as critical approaches to complex challenges, novel methods in evaluation, health economics. Recognise where you add value; the remit of academia is to develop robust evidence in response to complex and challenging questions using reliable methods – a gap that those in practice and /or policy cannot fill alone.
  • Find the right people to engage with – who are the decision makers in your area of research? Listen to what is currently important to inform action / policy. Read through local and national strategies in your topic of expertise to understand the wider landscape and where your work might inform, or where you might be able to address some of those key gaps. Academics can also submit evidence to policy (colleagues from the University of Bristol can access PolicyBristol’s policy scan, which lists current opportunities to engage).
  • Be visible and actively engage. Find out what local events are going on in your area related to your research and go along to meet local public health professionals. It’s a good way to meet people, find commonalities and form collaborations.
  • Condense your new research into a short briefing, identify what it adds to the existing evidence base, how does it inform given the wider context.
  • As an academic you will have a network of other research colleagues. Policymakers value being able to draw on this network for information. When providing evidence, don’t just cite your own – objectivity is one of the key advantages of working with academics, and policymakers value your intellectual independence. Your knowledge of the broader evidence base is invaluable.
  • Setting up a research steering group or stakeholder panel can be a great way to develop your relationships and ensure your research is speaking to policy, practice or industry priorities. Key to this is getting the right people involved – this blog post from Fast Track Impact has some useful advice.

The challenges of engaging with policy & how to navigate them

  • Academic and policymaking timescales are different. Policymakers need an answer yesterday while academics may not feel comfortable with providing a definitive response without time for reflection. There’s a need for flexibility on both sides.
  • There are also tensions between the perceived need for certainty and ability to be able to provide it. Policymakers may want ‘an answer’, but the evidence base may not be robust enough to give one. It is more useful to outline what we do and do not know, with a ‘balance of probabilities’ recommendation, than to say ‘more research is needed’.
  • Language can also be a barrier. Academic language is complex and, at times, impenetrable; policymaker documents need to be aimed at an intelligent lay audience, without jargon, and focusing on what matters to them (outlining policy options and the evidence base behind them – not lengthy discussions of statistical methods). Look at Public Health Wales’ publications, for example on digital technology, adverse childhood experiences and resilience, or mass unemployment events, or examples from the NIHR Dissemination Centre or PolicyBristol to get a sense of the language to use.
  • Do you think you have time for networking with non-academic stakeholders? The perception of opportunity costs can be another barrier for academics. While time for networking might not be costed into your grant funding, think of it in the same way as writing a grant application; you can’t guarantee the outcome but the potential reward is significant.
  • There are no guarantees in policy engagement work, and a level of realism is required around what findings from one study can achieve. Policymaking is a complex and messy process; the evidence base is just one factor in decision making. Your recommendations may not be taken up because of politics, resource issues, or other concerns taking priority. Sometimes your relationships will reach honourable dead ends, where you realise that interests, capacity or timescales are not as aligned as you thought. Knowing this before you start is important to avoid feeling disillusioned.
Cartoon showing complexity of policymaking process and comparing it to making sausages
Policymaking is a complex and messy process; the evidence base is just one factor in decision making. Image from Sausages, evidence and policymaking: The role of universities in a post-truth world, Policy Institute at Kings 2017

In summary, the panel concluded that policymakers are interested in academic research as long as their priorities are addressed. While outcomes are not guaranteed, our colleagues at PolicyBristol advise a strategy of ‘engineered serendipity’ – looking for and capitalising on opportunities, being ready to talk about your research in a clear and policy orientated way (why does your research matter and what are the key recommendations?) and aim to build long term and trusting relationships with policymakers.

If you’d be interested in attending a future Engagers’ Lunch, please contact Lindsey Pike.

Further information & resources

PolicyBristol aims to enhance the influence and impact of research from across the University of Bristol on policy and practice at the local, national and international level.

Public Health Wales Research and Evaluation work collaboratively across Public Health Wales and with external academic and partner organisations, and are keen to facilitate research links across Public Health Wales with new national and international partners.

Research impact at the UK Parliament ‘Everything you need to know to engage with UK Parliament as a researcher’

Parliamentary research services across the legislatures include:

  • House of Commons Library: an independent research and information unit. It provides impartial information for Members of Parliament of all parties and their staff.
  • Parliamentary Office of Science and Technology: Parliament’s in-house source of independent, balanced and accessible analysis of public-policy issues related to science and technology.
  • Research and Information Service (RaISe): aims to meet the information needs of the Northern Ireland Assembly Members, their staff and the secretariat in an impartial, objective, timely and non-partisan manner.
  • Scottish Parliament Information Centre (SPICe): the internal parliamentary research service for Members of the Scottish Parliament.
  • Senedd Research: an expert, impartial and confidential research and information service designed to meet the needs of Wales’ National Assembly Members and their staff.