Beyond the parish pump: what next for public health?

The complexities of integrating evidence-based preventative health into England's NHS: lessons learnt from the case of PrEP

BACKGROUND

The integration of preventative health services into England's National Health Service is one of the cornerstones of current health policy. This integration is primarily envisaged through the removal of legislation that blocks collaborations between NHS organisations, local government, and community groups.

AIMS AND OBJECTIVES

This paper aims to illustrate why these actions are insufficient through the case study of the PrEP judicial review.

METHODS

Through an interview study with 15 HIV experts (commissioners, activists, clinicians, and national health body representatives), we explore the means by which the HIV prevention agenda was actively blocked, when NHS England denied responsibility for funding the clinically effective HIV pre-exposure prophylaxis (PrEP) drug in 2016, a case that led to judicial review. We draw on Wu et al.'s (Policy Soc 34:165-171, 2016) conceptual framing of 'policy capacity' in undertaking this analysis.

RESULTS

The analyses highlight three main barriers to collaborating around evidence-based preventative health which indicate three main competence/capability issues in regard to policy capacity: latent stigma of 'lifestyle conditions' (individual-analytical capacity); the invisibility of prevention in the fragmented health and social care landscape related to issues of evidence generation and sharing, and public mobilisation (organizational-operational capacity); and institutional politics and distrust (systemic-political capacity).

DISCUSSION AND CONCLUSION

We suggest that the findings hold implications for other 'lifestyle' conditions that are tackled through interventions funded by multiple healthcare bodies. We extend the discussion beyond the 'policy capacity and capabilities' approach to connect with a wider range of insights from the policy sciences, aimed at considering the range of actions needed for limiting the potential of commissioners to 'pass the buck' in regard to evidence-based preventative health.

Systems leadership in practice: thematic insights from three public health case studies

BACKGROUND

'Systems leadership' has emerged as a key concept in global public health alongside such related concepts as 'systems thinking' and 'whole systems approaches.' It is an approach that is well suited to issues that require collective action, where no single organisation can control the outcomes. While there is a growing literature on the theory of systems leadership in a number of fields, there remains a lack of published empirical studies of public health systems leadership for professionals to learn from. The aim of the current project was to conduct cases studies in UK public health to provide empirical evidence on the nature of effective systems leadership practice.

METHODS

Three system leadership case studies were identified in the key domains of public health: health protection, healthcare public health and health improvement. A total of 27 semi-structured interviews were conducted. Data were thematically analysed to identify the components of effective systems leadership in each case and its impact.

RESULTS

The thematic analysis identified themes around 'getting started,' 'maintaining momentum' and 'indicators of success' in systems leadership. In terms of getting started, the analysis showed that both a compelling 'call to action' and assembling an effective 'coalition of the willing' are important. To maintain momentum, the analysis identified themes relating to system structure, culture and the people involved. Regarding culture, the main themes that emerged were the importance of nurturing strong relationships, curiosity and a desire to understand the system, and promoting resilience. The analysis identified three components that could be used as indicators of success; these were a sense of enjoyment from the work, resource gains to the system and shifts in data indicators at the population level.

CONCLUSIONS

This study has provided insight into the nature of systems leadership in public health settings in the UK. It has identified factors that contribute to effective public health systems leadership and offers a thematic model in terms of establishing a systems leadership approach, maintaining momentum and identifying key success indicators.

Processes, practices and influence: a mixed methods study of public health contributions to alcohol licensing in local government

BACKGROUND

Public health in England has opportunities to reduce alcohol-related harms via shaping the availability and accessibility of alcohol through the licensing function in local government. While the constraints of licensing legislation have been recognised, what is currently little understood are the day-to-day realities of how public health practitioners enact the licensing role, and how they can influence the local alcohol environment.

METHODS

To address this, a mixed-methods study was conducted across 24 local authorities in Greater London between 2016 and 17. Data collection involved ethnographic observation of public health practitioners' alcohol licensing work (in eight local authorities); a survey of public health practitioners (n = 18); interviews with licensing stakeholders (n = 10); and analysis of public health licensing data from five local authorities. Fieldnotes and interview transcripts were analysed thematically, and quantitative data were analysed using descriptive statistics.

RESULTS

Results indicated that some public health teams struggle to justify the resources required to engage with licensing processes when they perceive little capacity to influence licensing decisions. Other public health teams consider the licensing role as important for shaping the local alcohol environment, and also as a strategic approach for positioning public health within the council. Practitioners use different processes to assess the potential risks of licence applications but also the potential strengths of their objections, to determine when and how actions should be taken. Identifying the direct influence of public health on individual licences is challenging, but the study revealed how practitioners did achieve some level of impact, for example through negotiation with applicants.

CONCLUSIONS

This study shows public health impact following alcohol licensing work is difficult to measure in terms of reducing alcohol-related harms, which poses challenges for justifying this work amid resource constraints. However, there is potential added value of the licensing role in strategic positioning of public health in local government to influence broader determinants of health.