A commissioning framework for public health

Last week I was at the Guardian Public Health Dialogue in London, discussing how the new systems for public health will affect the UK. And eating crisps, of course.

For those of you who aren’t familiar with the Government’s plans, in a nutshell the responsibilities for the health of the public are moving into Local Authorities, the controversial new clinical commissioning groups, and a new central body called Public Health England. It was clear from last week’s event that even within the Department of Health and the NHS no-one is quite sure how all this is going to work yet, but it’s a big shift for public health delivery and could shake things up a lot.

I’m pleased to see Local Authorities having an increased role, because as Dr Quentin Sandifer at Camden Council said last week: “Everything that local governments do is public health.” Mental health in particular is deeply connected to social context, inequalities and living conditions, and so too are most of the really intractable social issues in communities today, from long-term worklessness to anti-social behaviour, poor diet, self-harm, drug-taking and alcohol abuse. Beyond the basic public safety responsibilities like protecting us from epidemics, public health in the UK today is really about improving people’s lives, and the best-placed bodies to take a whole-person approach to tackling this are Local Authorities.

I think the key obstacle to doing this well lies with the commissioning system. We hear a lot about the changes to NHS commissioning, but I still believe it is here that the new plans will come unstuck, unless we can shift our approach.

“Comissioning” in public services (still a relatively recent term) usually means paying third-party providers for a contracted service that they deliver on behalf of the State, whether that’s an NHS Trust running a sexual health clinic, or a private sector company delivering hospital IT systems. There is little sense in the UK of the concept of “State philanthropy” found in the US: most commissioning tends to be needs-based, with authorities identifying specific issues and tasking suppliers with solving them. Commissioning something purely because it makes people’s lives better is unusual, particularly in these austere times. The priority is on solving specific problems for specific people – a drug rehabilitation scheme here, an eating disorder support service there.

With the increasing drive towards payment by results, it will probably be the simple, easy to shift, highly measurable targets that get priority, because they are easier to commission effectively. Yet when you consider that the biggest cost-savings and radical efficiencies usually come from systemic, multiple-effect interventions, this is an issue that the Government should be taking seriously.

Public health doesn’t really work that way. Many of the most important public health questions in the UK today are simply too complex and interconnected to be tackled in isolation. A targeted intervention can be undermined by other factors such as the closure of key services, or wider social and economic factors. This is a particularly concern for our area, mental health and wellbeing, which  is notoriously difficult to measure and to affect through isolated interventions. With mental health issues costing the UK £77bn a year, and up to 50% of mental health problems seen as preventable by the Department of Health, the opportunity for systemic interventions in this area seems obvious.

Our particular interest at Mindapples is in helping people to take better care of their minds, which could support many areas of public health, just as the 5-a-day campaign has had a systemic effect on our physical health. It seems a no-brainer to me that if everyone in the UK takes better care of their minds, this will help address a great many health and social issues. But there seems to be no way in the current framework to commission this kind of systemic solution to multiple problems. Will public mental health fall through the cracks again?

I think the key to solving this problem lies in the outcomes frameworks.

Two weeks ago I was at a Department of Health meeting looking at the outcome framework for Local Authorities around public health. Whilst there are lots of excellent measures in there, many are too large and complex for any one commission to solve, making it difficult to know how anyone could commission effective interventions. For example, one proposed measure is the number of  hospital admissions for self-harm. The easiest way to commission services against this measure will be to work with people who have already self-harmed and put them through a process to help them recover. (Or, if you’re feeling cynical, to simply discourage people who have self-harmed from coming to A&E at all.) The harder thing to commission is something to reduce self-harm in the community at large, because it involves shifting a complex array of measures for the general population. Many public health issues work like this: simpler to treat than to prevent.

Complex problems require systemic interventions. The best councils are already thinking systemically, but the commissioning frameworks must reinforce this. If we are going to free up commissioners to try systemic, multiple-effect solutions to our most intractable public health problems, we need outcomes frameworks that include not only the symptoms, but the underlying causes of our public health issues. Moreover, by simplifying the objectives for public sector contracts, we can open up greater opportunities for small service providers, community groups and social enterprises, who currently lack the resources to deliver or measure against such weighty outcomes.

We are used to doing this in other areas. For example, we don’t expect Councils to tackle economic growth on their own: we make strategic economic decisions and task Local Authorities to deliver specific, measurable, tactical outcomes, such as offering small business support. So what are the simple things which Local Authorities can do, which collectively will contribute to a step-change in the health of the nation?

For one, we urgently need to start measuring locus of control. Clinical evidence is stacking up to show that if people feel they have control of their lives, they are likely to be mentally and physically healthier, with or without seo services. If we measure this across communities, and particularly amongst users of public services, we can easily start commissioning to promote this. There is similar evidence around self-esteem, education, loneliness, social capital, sense of community, and perceived inequality. We can commission interventions in all these areas, and measure them relatively cheaply too.

The job of Public Health England, in my view, should be to review the evidence base and understand the overall issues facing Britain, and to task commissioners with moving indicators that they can easily measure and effect, but which collectively add up to big change. Their job is to be the national experts in these matters, setting the agenda and driving a national strategy for change in public health, not simply passing the streategic decisions on to local level. Get these measures right, and we can make progress quickly. Get these measures wrong, and we will be stuck with more of the same – or rather less of the same.

Public health, and particularly public mental health, represents a huge opportunity to improve people’s lives and make Britain stronger in today’s tough global economic climate. The sooner we see this, and make plans to do something tangible about it, the better for everyone. It’s time for the Government to lead the way on building the evidence base and deciding the tactics, and free the rest of us up to do what we’re good at: helping people feel better.

Posted by Andy


Nudge vs. #bigsociety?

Happy New Year folks, I hope you had a lovely mindapple-filled winter break. Last week I attended the launch of the Health Equalities Alliance and their inaugural debate Nudge or fudge – can a gentle push really tackle health inequalities? It was the first time I’ve had the chance to quiz members of the Cabinet Office’s Behavioural Insight Team about their recent emphasis on ‘nudge’ social marketing techniques, and it’s given me much food for thought.

Nudge, for the uninitiated, refers to a set of techniques described in the book of the same name by Richard Thayler and Cass Sunstein, about the unconscious influences which “nudge” us make choices in everything from the food we eat to the directions we walk. Anyone designing an environment in which people make choices is a “choice architect” and witting or unwittingly creates factors which influence decision-making – and which can therefore be altered to nudge people to make choices which are better for them.

This is nothing particularly new. The techniques are drawn from the same psychological stock as 20th Century advertising, PR and sales theory and are well-evidenced. The Coalition though sees these tools as pivotal to delivering mass behaviour change in high cost areas – such as public health – at a low cost. When you consider that a recent Scandinavian study (citation appreciated if anyone can find it) suggested the health service contributes only 15% of the overall health of the population, you can understand why nudge theory is so appealing to an indebted Government facing rising demands on an already over-stretched NHS.

The problem though, as many of the panel observed, is that you can’t nudge people out of poverty. To put it more broadly, choice architecture works brilliantly when you have a choice, but is therefore more likely to benefit the wealthier classes with more options than those who cannot afford better food, or who are subjected to abuse or poor living and working conditions. I am skeptical about the capacity of nudge thinking alone to deliver health equalities or even widespread population health improvements, at least beyond the priviledged minority. It must be blended with real progress on the critical social factors that create poor health, and not a substitute for them. I also welcomed the assessment of Phil Coppard, Chief Executive of Barnsley Council, that dividing public health into individual behaviours like smoking, diet and exercise misses the underlying truth that “this is actually about low level mental health”. Nudging people to act differently may alleviate the symptoms, but leave the sickness untouched.

I believe that nudge thinking has an important role to play in improving the design of public systems and spaces, by making designers think more carefullyabout the implicit choice architecture embedded in their creations. For example, my council landlords require me to sort recycling into several piles and take it out into the street, but if I want to send anything to landfill they will collect it daily direct from my door. Then they put up leaflets about the importance of recycling. This is patently absurd, and if nudge thinking can be used to review and correct the nudges that send people in the wrong directions, this is a good thing.

However, I also believe there is a tension between the implicit paternalism nudge thinking and the “empowerment” rhetoric of the Big Society (and more on my personal thoughts on that project over here). Dr Samantha Callan from the Centre for Social Justice cited one example of nudge in action, that of placing a bus stop outside a care home so that if Alzheimer patients ran away from their carers, they would simply wait outside for a bus until they could be collected. So far, so economically efficient. But as one audience member observed, perhaps this is manipulating patients to stay indoors rather than helping them spend more time outside rather than cooped up indoors all day. Sometimes we do things unconsciously for good reasons, even if the result isn’t as effective as we would like. Moreover, nudging people in one direction rather than another still leaves them vulnerable to being nudged back again, and when you consider that for every pound spent on nudge public health marketing there will be ten spent on getting the public to eat Pringles, the economics of this whole nudge thing start to look flawed. Nudge is powerful, but unless it builds conscious agency and involves individuals in the decision-making process, it can only disempower the people it serves.

How can we be trusted to run our communities, deliver public services and control local planning decisions when we cannot also be trusted to make informed decisions about feeding ourselves or raising our children? We cannot be nudged into taking more informed responsibility for our life choices. So are the people who are to be subconsciously manipulated into living healthier lives the same people who the Government is championing as having the power and skills to lead this country into a new era of citizen-led society? Or will we be nudging one part of the population whilst empowering another?

With this in mind, my question to the panel was “have we abandoned learning?” Dr Ronny Cheung from the Cabinet Office (who took more than his fair share of flak from the audience as the only official nudge apologist present) spoke of nudge as more effective at scale than “giving information” – but giving information is simply old-fashioned broadcast style education. There are so many more sophisticated tools for creating learning than giving information, and if we fail to employ any of them in tackling public health issues, we are effectively giving up on having an informed public who are responsible for their own destinies. We need to engage the public in making conscious choices and building personal habits based on knowledge, to empower individuals not only to manage themselves better, but also to resist being nudged in one direction or another. And if we are to capture the support of the current Government, we also need to do it at scale, and cheaply.

This is where I think Mindapples comes in. We want to build people’s conscious awareness of the connection between what they do and how they feel, and help all of us learn from each other what we each want and need to be mentally healthy. I’m sure we’ll be nudging people along the way, but everything we do will always be about helping individuals make conscious, informed choices about what they need, and getting the support they deserve to meet those needs. And we think we can use digital tools, peer recommendations and the skills and networks of our community to do this at scale, and for low cost. When you consider Mr Coppard’s observations about the root causes of many public health issues, an effective and empowering intervention in public mental health could have huge positive implications for public health in general.

Of course, education on its own is not enough. Professor Richard Parish of the Royal Society of Public Health summarised it well last week: “we haven’t abandoned education, but whether education results in behaviour change depends on social factors.” Mindapples and its like can go some way towards helping people get what they need from society, but there is still much that the Government must do to create the opportunities for people to thrive, and the social and cultural context in which good things are easier to do.

Right now though, we seem to be in the strange position of pushing subconsious behaviour change techniques to a passive, unaware population with one hand, whilst the other lifts citizens up to run our communities, take vital decisions and run public services. Is the pragmatic paternalism of nudge politics actually in direct conflict with the lofty aspirations of the Big Society?