how will evidence-based public health fare in the world of...

School for Public Health Research16/10/14

Politics, Localism and Epistemologies of Practice

Judy Green – HSRP, LSHTM

Gemma Phillips – CPHS, University of Edinburgh

This is an outline of independent research funded by the

National Institute for Health Research’s School for Public Health Research (NIHR SPHR).

The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR

or the Department of Health.

16.10.14

How will evidence-based public health fare in the

world of local government?

School for Public Health Research

The University of Sheffield

• The University of Bristol

• The University of Cambridge

• University College London

• The London School for Hygiene and Tropical Medicine

• The Peninsula College of Medicine and Dentistry

• The LiLaC collaboration between the Universities of Liverpool and

Lancaster

• Fuse; The Centre for Translational Research in Public Health, a

collaboration between Newcastle, Durham, Northumbria, Sunderland and

Teesside Universities

The National Institute for Health Research’s

School for Public Health Research (NIHR SPHR)

is a partnership between:


Local Government


Public Health and Local Government

The new arrangements could enable a

more joined up approach across

sectors and greater collaboration with

citizens and communities. Local

authorities could make a shift from a

medical to a social model of health,

providing a real opportunity to refresh

what we mean by public health.

David Hunter et al. in The Guardian 2014



Politics & Health

…although public health budgets transferred to local government are

ring-fenced, it is already clear that cash-strapped local authorities might

redesignate many of their existing activities as public health, citing the

slogan “public health is everyone's business” in a way that was never

contemplated.

(Mckee et al., The Lancet 2011)



Evidence

Public health staff also have skills in evidence-based prioritisation,

evaluation and assessing outcomes. With budgets getting ever smaller,

and new opportunities such as the Better Care Fund, there should be a

chance to put these skills into practice...

(Andrew Furber – DPH Wakefield, The Guardian 2014).

…the practice of evidence based public health (EBPH) needs to become

universal and routine to ensure that scarce resources are directed at the

efficient roll-out of evidence-based interventions.

(David Conrad - PHE, JECH 2014).


Public Health & Local Government

Philosophical

‘Health’ is contested – individual vs. social

Neutrality/objectivity of ‘evidence’

‘Evidence’ is contested within PH

Practical

Local Government – the unknown


Aims

Look in detail at how decisions are taken in service areas of local

government that impact on the social determinants of health

Rationales

Knowledge resources

Produce a grounded understanding of local government practice and

knowledge creation/application

Stimulate thinking on how public health can work in local government


Evidence in Local Government?

Research

findings

Needs

assessments

Public opinion &

professional

experience

Expert opinion

National guidance

Cost-benefit

analyses

Literature reviews

Case studies from

other locations / Best

practice

Local data

Informal public

consultation

Lorenc T et al. Cultures of evidence across policy sectors: Systematic review of qualitative evidence. European Journal of

Public Health Epub 2014.


Methods

Ethnographic approach

8 weeks participant observation / non-participant observation

Internal meetings

Informal conversations

Work visits with officers

Public meetings

In depth interviews

Alcohol related work

Semi-structured interviews in other LA areas and services

Organisational ethnography approach

Focus on practice (officers)

Not following evidence/policy through different fields


Local Government & Legislation


Local Government


Local government organisational structure

Councillors Officers

Lead Councillor

EM: Children & Young People

EM: Health & wellbeing

EM: Community Safety

EM: Performance

EM: Communities

EM: Housing

EM: Environment

Chief Executive

CD: Children

CD: Environment

CD: FinanceCD: Governance

CD: Housing & Adult Services

CD: Strategy

CD: Public Health?

SD: Refuse/ parking/

streets / parks

SD: Licensing /EH/

Trading standards

SD: Planning

SD: Leisure/ Energy/

Transport

Committees: Licensing, Planning, Scrutiny

(health, environment, communities)

SERVICE

MANAGERS

OFFICERS


Findings

Research questions

Decision-making in practice

Applying knowledge - rationales & knowledge resources

Creating knowledge / Assessing practice


Decisions making in practice

Managing multiple stakeholders

Middle-

ranking

managers

Local

residents

National

government

Local

businesses

Councillors Executive

directors

External

funders

Human

resources



Managing multiple stakeholders

It’s our job to sort of work with members and devise policy,

implement it and then in my case, because I do a lot of statutory

work, it’s around making sure that we comply with all the kind of

legislative requirements that are on us. And, you know, that we

apply the way that we do that to a kind of level that’s responsive

to our population...

(Service Director)



Managing multiple stakeholders...one of the parties at one point at election time said that they

wanted to give free school meals to every child in the borough.

And so with something like that the officers can work before the

election ... so that if they do get in, they can present them with

some options. But it’s all the other policies that are more

complicated... we have to say to them, well you can’t really

change these things, because of x, y and z reason. And so we

have to work with them to find the bits around the edge that they

can tweak.

(Service Manager)


Negotiating health outcomes

Middle-

ranking

managers

Local

residents

National

government

Local

businesses

Councillors Executive

directors

External

funders

Human

resources

HEALTH?


Summary

Decision making in practice - Politics

Multiple stakeholders – conflicting & changing agendas

Health is one of many agendas - legislation

Health is drawn on strategically but not claimed as work

Role identity – negotiator, arbitrator


Ways of knowing: hard data, seeing

problems and the localityInterviewer: So the, did you consider other areas in the borough

for the saturation zone that you didn’t select, or?

Service Manager: Um in reality, no, because we very much, we

use the um, the alcohol crime data to sort of give us a framework. And

then we did look at what we, our sort of local knowledge on, on areas.

So say, for example, you’ll probably find between here and up to the

High Road, probably doesn’t feature hugely on um any hotspot map,

but we know that there are a number of premises in the area and we

wouldn’t want the, any more new premises in the area might just tip

the balance.


Ways of knowing: hard data, seeing

problems and the locality

... because I see so many different off licences, I can give an

authoritative comparison between what might be a well run

business and the one that we’re reviewing, which is not likely to

be a well run business... [I’m] not necessarily too worried about

consistency or apparent consistency. Because I know that my

thought processes are consistent and it may on apparently

similar facts come to a different decision, but there will always

be a [with] bit of delving, there will always be some sort of

explanation for that.

(Trading Standards Officer)


Summary

Politics


Health is one of many agendas



Knowledge

Detailed local knowledge comes from direct contact – throughout hierarchy

Data are interpreted from empirical expertise


Transferring practice

I mean best practice is, sometimes you think, oh that’ll be great

but we haven’t got time to do it, so it’s like, it isn’t a priority for us

so it’s going to take, you know, it might be good practice but it is

a priority for you, or have you got the resources to do it, really?

Does it fit in with what you’re doing really?




I can’t even remember where we got the idea from... I think it

might actually be that probably I was looking to see what [a

neighbouring authority] had done in their policy... So then it

made sense to see if we could incorporate that into the

Licensing Policy in some way... so we basically [laughs] copied

what they’re doing, which makes sense [laughs].

(Service Manager)



We compare ourselves to a lot of European cities and, and they

tend to be the most progressive and, you know, innovative as

well, so we’re always looking abroad... we’ve probably got more

in common with other metropolitan cities around the world than

we have say, you know, parts of Devon or Cornwall.

(Transport Planner)


Summary

Politics





Knowledge



Localism

Uniqueness & competition

Standardised and transferring best practice not a priority


Creating Knowledge

Evaluating outcomes: for whom?

Officers

Local residents

National government –

legislation/ initiatives

Local

businesses

Councillors Chief

executives

External

funders

Man power

Other local

agencies

Performance management/Auditing

Feedback

Reporting –

evaluation /

delivery

Cost-savingsFit with strategy


Performance Management

We’ve got, sort of national performance targets, the food ones

are good examples of that. Sometimes they might just be local

targets that we set ourselves... every team has a set of targets.

And every officer knows how they contribute and what they’ve

got to do.

(Service Director)



I think things like the literacy festival we tried to do a little in-

house evaluation of that, what worked and what didn’t. And

sometimes it might be quite crude, just sort of feedback sessions

or, you know, giving out questionnaires and collating that. Um,

and sometimes it’ll just be around the sort of reception it gets,

so, you know, if it got, if something worked really well and we got

good feedback from the community members then, you know,

we’ll repeat it.

(Service Director)



Well I mean, I think the key benefits for... us in Trading

Standards was... the positive aspect of working with businesses

... that was of real value to us... the problem with the statistics

because they’re quite small areas, was that... there was a

reduction in ASB [anti-social behaviour orders] but not a huge

reduction.



Summary

Politics





Knowledge



Evaluation is about accountability & evolving practice

Localism

Uniqueness & competition

Standardised and transferring best practice not a priority


Reflections

How can public health work in local government?


NIHR

Judy Green

Mark Petticrew &Theo Lorenc – comments on the paper

Karen Lock, Elizabeth McGill, Fred Martineau, Jo Akhgar, Matt Egan

Participants

Thanks to

School for Public Health Research16/10/14

Politics, Localism and Epistemologies of Practice

Gemma Phillips & Judy Green

LSHTM School for Public Health Research

This is an outline of independent research funded by the

National Institute for Health Research’s School for Public Health Research (NIHR SPHR).

The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR

or the Department of Health.

16.10.14

How will evidence-based public health fair in the

world of local government?

how will evidence-based public health fare in the world of...

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