Need to work across all three
4.2.3 Ranking of criteria
Participants were asked to rank 14 criteria that could be used to decide whether or not to invest in an intervention: a rank of 1 = most useful through to rank 14 = least useful. The 14 criteria were:
cost of intervention effectiveness
cost-effectiveness score population eligible
impact on health inequalities burden of disease
cost saving in less than 5 years cost saving after 5 years
acceptability affordability feasibility
quality of evidence certainty
non-health effect (benefits in health and other public sectors for example education, criminal justice).
They were able to add and rank other criteria that they felt were relevant.
Only one respondent suggested an additional criterion which was ‘overall impact on health’ and ranked it first equal to the rank given for the criterion ‘impact on health inequalities’. The same respondent also commented that the criterion of ‘cost saving in less than 5 years’ should be reduced to ‘less than 2 years’ for the NHS. The respondent also explained that the high score of 3 for ‘effectiveness’ only applied if multiple outcomes are considered and that a low score of ‘12’ had been applied to
84 the ‘cost effectiveness’ because the perspective of the analysis can be limited.
A second respondent gave a rank of 6 to ‘non-health effects’ and commented that these effects would become increasingly important, particularly in terms of impact on jobs.
The ranks of the individual respondents and median ranks for each of the criteria are shown in table 8. The criteria are organised in rank order based on the median value for all respondents. Note: two respondents (R6 and R7) did not score each and every criterion so their results have been omitted from the calculation of the median and overall ranking.
Table 8 Usefulness of criteria for making investment decisions
R1 R2 R3 R4 R5 Median Rank R6 R7
Not all of the participants returned the ranking exercise and so like the sample of health sector participants, the sample size of local authority participants is small and opportunistic. Nevertheless, the following observations were made:
The criterion ranked as most useful for decision-making was impact on health inequalities and the second most useful was cost effectiveness.
There were substantial variations in participants’ rankings of the individual criteria. For example, ‘health inequalities’, which was ranked the most
85 useful criterion overall had a range of scores from 1 to 7. The ‘cost
effectiveness’ criterion which was ranked the second most useful ranged from 1 to 12.
Although the sample sizes for the health and local authority sectors are quite small, comparison of the two rankings for these two sectors suggest they may differ in the relative importance they place upon the criteria that could be used to support decision-making. For example:
Local authority participants ranked health inequalities more highly than health sector participants (first versus fourth).
Local authority participants ranked interventions that are cost saving in less than five years more highly health sector participants (fourth versus ninth).
Participants from both sectors ranked cost effectiveness as the second most useful criterion.
Effectiveness featured among the top three rankings for both health sector and local authority participants.
Health sector participants ranked affordability more highly than local authority participants (third versus sixth).
Health sector participants ranked burden of disease more highly than local authority participants (fifth versus eleventh).
The analysis of the ranking of criteria is limited by the number of workshop participants who returned the ranking exercise. As the findings potentially have important implications for the information necessary to support local decision makers, further research with a larger sample size of decision makers, particularly those within the newly established NHS, public health and social care commissioning frameworks, is necessary.
4.3 Analysis of public health guidance
Overview
The 26 pieces of public health guidance analysed contained a total of 168
86 recommendations. The number of recommendations made within each piece of guidance ranged from as low as 3 to as many as 24. In addition, each
recommendation frequently contained more than one ‘action’ bullet and on occasions multiple sub actions.
Throughout the pieces of guidance multiple sectors were asked to take action. The sectors included the NHS, primary care, local authorities, the voluntary and
community sector, education, criminal justice and the private sector. Frequently these sectors would be mentioned together and therefore all be asked to undertake the subsequent actions. Two of the more recent pieces of guidance, ‘Alcohol use disorders – preventing harmful drinking’ and ‘Prevention of cardiovascular disease at a population level’, included recommendations to government.
Many of the guidance documents were structured to lead the reader through the recommendations in a logical manner from an initial needs assessment to set up through to intervention. The recommendations contained an array of different elements/actions. These included the need for strategy development, partnership working, investment, training, needs assessment, service provision, identification, intervention and follow up. Some recommendations contained multiple elements, for example they may cover the need for identification, intervention and follow up.
The guidance documents contained a range of recommended interventions including the provision of advice and education, pharmacotherapies, changes to the physical environment and the introduction/amendment of legislation. It should be noted that in some pieces of guidance it was recommended that interventions should be tailored to the individual in question. The predominant framework that covered the
interventions was that of ‘informing and supporting’.
In terms of the target populations and their position within the life course, the current suite of public health guidance appears to cover most stages of an individual’s life. It includes children at many different stages (pre-natal, school) and adults (family, employment) including older adults.
87
4.4