4.1 Workshops with commissioners and decision makers
4.1.1 Group work – scenarios
As noted earlier, part of the workshops took place in small groups and used
scenarios as a way of facilitating discussions around the context, opportunities and barriers for local decision-making processes to prioritise public health interventions.
By sharing their experiences, participants were expected to raise issues that NICE needs to take into account when developing tools to assist local decision-making.
The scenarios were:
Scenario
A
£Xm8 ring-fenced budget for (for example, alcohol, smoking, obesity, physical activity) – how would you decide how best to
8 For Cambridge, the amount was £1m in each scenario and feedback was that this was too low, so it was changed to £10m for the Manchester workshop.
71 spend? (that is, which interventions). If ring-fenced budgets
don’t exist please just take as money available.
B
£Xm ring-fenced budget for public health – how would you decide how best to spend? (that is, which topics and
interventions?) If ring-fenced budgets don’t exist please just take as money available.
C
£Xm saving9 (the group needs to make explicit their definition of a saving) to be found across health (clinical and public health) – how would you approach this?
D
£Xm saving (ditto scenario C definition of saving) to be found across public health – how would you approach this?
E
Making the business case for public health interventions – what do you need to know? What should be included as part of the case?
A number of questions were used as prompts by the facilitators. The feedback from each group has been organised under these and other key themes:
People involved in making the decisions
A range of people can be involved in helping to assess need, prioritise and make decisions about which health issues and interventions to invest in.
It can include public health practitioners, clinicians, finance, local government and other partners within the local health economy. It is important that both
commissioners and providers are involved in the process.
It can also mean consulting with the public, but being careful that issues do not become overly political.
In terms of decision-making, in some cases it might come down to one person (for example director of public health). In other cases, decisions are made by the full executive management team, in cooperation with those who are proposing (and making the business case for) the potential projects.
9 Cost savings were sometimes categorised by the participants as cash releasing;
cost avoidance; efficiency/productivity and/or added value.
72 Data and sources used or needed to make an informed decision
The Joint Strategic Needs Assessment (JSNA) is usually the starting point to identify local priorities and needs of different population groups. Localities need flexibility to commission according to local intelligence about needs.
The data and sources cited include:
NHS Evidence NICE guidance
public health guidance other (general, clinical) PHO (Public Health Observatory) SHA targets
Cochrane reviews
York health economic data Stakeholder consultations
Service activity data (health and social care) Financial data
Prevalence data
Health needs assessment (including JSNA) Project evaluations.
Existing decision making tools and processes
Some people use prioritisation tools to aid decision-making, however these do not make the decision for you. Examples of some of these can be found in a review of prioritisation tools and frameworks undertaken by Yorkshire and Humber Public Health Observatory (available at
www.yhpho.org.uk/resource/item.aspx?RID=69847).
73 Some of the tools mentioned in our workshops were:
NICE costing tools PHO work
EPACT (prescribing) analysis local government reviews.
A typical decision-making process might be:
review of all public health programmes with specific reference to what works (what is the evidence base behind the investment decision) link this to the population needs assessment
match what works with population needs, and then
disinvest in what is least cost effective and not a major local health problem.
Most people cited the world-class commissioning criteria. Some referred to decision-making tools such as MCDA, possibly using a decisions conferencing approach where all stakeholders are involved in determining the costs and benefits and rank interventions according to locally determined criteria. This needs to engage a wide range of stakeholders. Some PCTs use a clinical priorities forum involving clinical staff (GPs and secondary care clinicians) and use clinical priorities policies to rank interventions.
Other approaches included using prioritisation templates, where you take how much money you have and then you spend as you go through your priorities.
Difficulties in making decisions Some of the difficulties cited were:
political – visible, challenging disinvesting
74 information on what to disinvest in would be very useful
for each intervention NICE recommends, it should identify others that could be replaced. Otherwise both will continue to be
used/funded
avoiding expenditure on interventions with no evidence base reducing duplication
increasing productivity
robust evidence-based outcomes and commissioning social value judgements have to be made
strength/validity of the data not certain realising real savings
need will always outstrip supply
saved beds from one person/condition will be filled by someone else
either cut programmes, cut staff costs or use cheaper interventions acute sector savings are falls, vaccination, alcohol, smoking, drugs organisations want quick savings but pubic health benefits may take 10 years
difficult to assess impact on other sectors (education, housing and so on) – critical when involving local authority in discussion about priorities in public health.
Convincing commissioners and decision-makers to invest in public health over other topics: in the very short- (less than 1 year), short- (1 to 3 years), medium- (4 to 10) and long-term (over 10 years)?
Commissioners need to be able to cite concrete outcome measures that are easy to understand, for instance 100 myocardial infections (MIs) avoided and 1500
admissions avoided.
75 There was some diversity in the use of timescales, with trusts facing large deficits operating on 1-year timescales at best, and others looking forward (though not comfortably) up to 5 years. There is a need to show when and where the benefits fall – from a return on investment perspective, it needs to be less than 5 years (although there is often the need to invest for at least 3 years to reap the benefits). Most
agreed that early returns on investment and quick wins (less than 1 year) are crucial.
Some of the criteria have already been reported above. Others cited were:
local intelligence about needs
evidence-based services and interventions cost implications in terms of capital and revenue health outcomes
in terms of health gain impact on health services
ideally quantified in terms of cash impact on health inequalities
value for money cost effectiveness
in a language that can be understood by lay audience
QALYs not useful, prefer first year rates of return, 1−3/5 year costs/savings (hepatitis C example)
affordability – the cost per QALY does not reflect affordability – knowing cost or saving for x number of people in every 100,000 would be helpful healthy life expectancy and cost effectiveness of primary prevention versus secondary/tertiary prevention
national targets and priorities
76 sustainability of interventions (some, like health education for diabetic patients, help only the cohort trained; others, like paths for walking or cycling may produce ongoing benefits).
Local authorities
Several participants mentioned the importance of the local authority audience for NICE and current guidance is not in the language/format local authorities can relate to. Unfortunately, the impacts of public health interventions beyond the NHS are often not well understood or articulated. A better appreciation of potential conflicts, synergies, overlaps and gaps would be helpful. They suggested that NICE looks at big spends for local authorities and produces guidance in these areas.
Cross sector/joint commissioning/pooled budgets
In future, it may be more common to consider non-NHS budgets, including local authority (for example, spend on leisure) and the wider local economy.
The White Paper on the NHS, Equity and excellence: liberating the NHS
(Department of Health, 2010b),was released in time for the Manchester workshop and referred to ring-fenced budgets for public health. Some participants felt that although ring-fencing may encourage longer-term outcomes, this will depend on what is included within ‘public health’. For example, the provision of statins may be preferred over other interventions because it has a more immediate impact.
Importantly, when asked about the potential to achieve cost savings, participants in the workshops shared similar views. In Manchester, workshop participants
commented that cost savings could only be realised by cutting back on services, for example, by closing a hospital or shifting the flow of patients from expensive services to cheaper (and more appropriate) services (that is, moving people from secondary to primary care, and from primary care to community care (for example pharmacy) and/or self care).