Public Health Outcomes Framework

I’ve written before about how data is likely to drive decisions in what gets done in public health so it’s useful that there is now a Public Health Outcomes Framework website which provides quite a lot of information at a locality level.

So below is a screen shot of a heat map depicting the number of first time entrants to the youth justice system per hundred thousand of population.

first time youth justice

There’s also regional level data – below are the proportions of pupil absence in the North West.

north west

And the site lets you drill down to council level, below are some of the statistics for Birmingham that relate to the wider determinants of health as measured amongst young people.

birmingham

Users can see the outcome of drug treatment, the vast majority of whom will be adults (as you can see in the heat maps below this is broken down by opiate users and non-opiate users). As yet the alcohol related outcomes don’t appear to be available, nor are the prevalence data for smoking, drinking and drug use by young people, though if this tweet is anything to go by there are plans to keep adding to the data sets.

treatment outcomes

Another prevention metaphor

Catch A Falling Star... by peasap
Catch A Falling Star…, a photo by peasap on Flickr.

I quite like this as a metaphor for why investing in prevention is a good thing:

Imagine a bucket full of health. This bucket has a hole in the bottom and the health is dripping out (disease). We can mop up the floor below every hour, maybe even squeeze some of the health back into the bucket from the mop. But eventually, the health will be lost because we are not addressing the root of the problem. Instead, we can look for ways to prevent the hole and stop the leak from occurring.

via The Conversation.

Also this use of Prezi to explain the Social Determinants of Health is really impressive.

‘On the state of the public’s health’ – CMO’s annual report

The Chief Medical Officer for England has produced her first annual report, Professor Dame Sally Davies says:

Fair Society, Healthy Lives notes that only 4% of NHS funding is currently spent on prevention. Given the health burden attributable to risk factors, there is a clear case for arguing for this proportion to be increased. This is not new: the final report of the review led by Sir Derek Wanless looking at the resources required to provide high quality health services in the future, projected that a substantial reduction in costs could be achieved by an increased emphasis on prevention, coupled with higher levels of public engagement in relation to their health.

However, while she does talk about preventative services quite a lot in Chapter 6 of the report when it comes to tobacco, drug and alcohol services the focus is treatment and recovery rather than upstream interventions.  Interestingly she does call for much more focus on alcohol which she says has been a poor relation to drug services.

This is also reflected in Chapter 3 where she highlights risk factors for poor health including the abuse of drug, alcohol and tobacco, but again the focus is on over 16s rather than on younger adolescents.

That said Dame Sally does set out her reading of a life course model which describes the influences on health.  As you’ll see from the graphic representation (above) there is a strong recognition that we need to build skills and knowledge during childhood and adolescence which she describes as including:

all life skills (from social skills and resilience, to vocational skills), and knowledge gained through all forms of direct and indirect education.

From my perspective the way that Dame Sally has set out her thinking suggests that for those of us focusing on preventing drug and alcohol misuse still need to find a way of describing how we can make a contribution to better health in ways that will encourage those in public health to invest in the sorts of interventions we’re trying to develop.  At the moment there is some sympathy for increasing the role of prevention, but what is meant by that seems quite different to the way that we might think of it.

Life Course

One of the concepts that appears to be gaining considerable traction in policy making is the adoption of a life course approach.

As the diagram above (taken from this presentation on the Good Behaviour Game)  shows this is another way of talking about what I’ve been calling the ‘sunscreen’ approach to prevention.

What this recognises is that determinants of health behaviours that may manifest in adult life can be set before a child is born, and that there are things that society can do to mitigate those risks.  It goes on to argue that putting in place these earliest interventions isn’t sufficient, and that the ideal we should be aiming for is to address risks and bolster protective factors throughout our lives.

This fits really well with our own philosophy of prevention.  We’ve never argued that single interventions on their own are sufficient, nor that those interventions should be limited to a single setting.  Rather we’ve tried to make the case for a broad-based strategy that works where children and young people are, that is age appropriate, and that mixes population level interventions with programmes that help groups and individuals gain the skills and values that will protect them from the harms of drugs and alcohol.

Determinants of Health

I’ve mentioned the important work that Sir Michael Marmot has been doing about what causes people to get ill, or to take risks with their health before on this blog.

If you want to hear him and some of his critics talk about social epidemiology and to understand how it is contributing to health policy here and across the globe then the BBC’s Analysis programme has a very balanced and interesting take on it all.

You can either listen again or read the transcript.

Social Determinants of Health

If you’re having some difficulty in understanding the concept of the social determinants of health, the “causes of the cause’s” of ill-health, the National Social Marketing Centre have produced a few films that are case studies of how particular communities and projects are trying to come at the things that make us less well.

This one is about treating young people for their drug and alcohol problems in Copenhagen.

The Challenge of Marmot

Photo by Flickr user Roadsidepictures

In a recent appearance before the Education Select Committee the Secretary of State, Michael Gove is reported as saying that he wanted to be “deliberately controversial” when questioned about the role that schools play in helping pupils avoid risky behaviours.

He said:

“if you look at the way in which we can encourage students not to indulge in risky behaviour, one of the best ways we can do that is by educating them so well in a particular range of subjects that they have hope in the future.

“There is a direct correlation between how well students are doing overall academically and their propensity to fall into risky behaviour.”

For those of us pressing for compulsory health education this comes across as short sighted and complacent; how is this compatible with the promise to prioritise prevention as outlined in the Social Justice Strategy just published?

We point to the evidence that a number of programmes have shown good impact on risky behaviours, we argue that these programmes can help improve educational outcomes, that they’re cost effective, and that young people should have an entitlement for good health and wellbeing education.

But, a new publication from the Institute of Health Equality (IHE) (which was launched in November 2011 to build on the work of the Marmot Review) asks us to think again.  They suggest that the approach to public health is too often ‘downstream’ of the things that make a real difference to health inequalites.

While downstream interventions do have a mitigating impact and can reduce the extent of health problems, they usually fail to address the root of the problems. This will be best addressed by tackling the causes of the causes further upstream and using a whole system approach to delivering interventions effectively and according to an area’s needs.

 This may sound like music to the ears of those of us in the prevention field, but the Institute are quite clear that school based prevention programmes (for example) are an ‘upstream’ intervention.

They use the phrase ‘lifestyle drift’ to describe how public health practitioners are drawn back to intervening in behaviours rather than addressing the social determinants of health (SDH) (the causes of the causes).  This happens for a number of reasons:

  • Behaviours are easy to identify and easy to design interventions around (even if they’re not effective).
  • National policy is designed and analysed around behaviours.
  • It takes a really long time to see the effect of SDH.

 So, a school programme that tries to develop the life skills of young people in order to effect drug or alcohol use addresses behaviour, while what is really needed is to address the causes of the causes. And it is hear that we return to Michael Gove and the strategies that being pursued by the government to address school failure, tackle truancy, improve academic outcomes, and to tackle youth unemployment.

There is little doubt that the IHE would see these national government policies as being of much more importance for the future of public health than the delivery of evidence based programmes in schools.  Which may be why we see a public health outcomes framework that includes indicators such as school readiness, truancy rates, the number of young people not in education, employment or training, and first time entrants to the youth justice system.

Whilst it would be a foolish thing to argue that tackling the causes of the causes shouldn’t be something that Health and Wellbeing Boards focus on there may be good reasons that they should have a slightly wider view which encompasses trying to the causes of ill health too.

However, the challenge that the report sets us is to think more deeply about whether our efforts to prevent substance misuse can be drawn in a way that can add value to tackling the ’causes of the causes’ that a social determinants of health approach might indicate.

Sidenote

The report also sets out some principles for Health and Wellbeing Boards when commissioning services that look really useful.  They are:

  1. Address the area’s wider needs (Intervention likely to impact on the greatest needs of the population as identified in the JSNA, regardless of what sphere the intervention takes place in and allowing for the fact that the timescale needed for an impact on health outcomes might be long)
  2. Is universal and addresses the social gradient in health (Intervention likely to impact on the whole population, but provides more intense support to those in greater need, with less socio-economic resources, or living in areas of greater economic or environmental deprivation)
  3. Is aligned with other local and national policies (Intervention does not interfere with other policy objectives, e.g. sustainability, and is likely to have positive impact on other social outcomes and performance indicators)
  4. Is backed-up by evidence of efficacy (Intervention considered because there is evidence strong evidence base that it is likely to have an impact on the SDH and on health inequalities)
  5. Is cost-beneficial (Intervention likely to positively impact on long term costs to health and social services, and to provide significant social gains for its cost)
  6. Takes advantage of existing assets and resources (Intervention makes efficient use of existing service infrastructure and enhances the availability and quality of community resources)
  7. Provides the population with control over their lives (Interventions devised on the basis of clear community priorities as stated by consulted stakeholders and users; intervention engages the public in decision-making and delivery)
  8. Falls within one of the following unifying themes:
    1. The importance of improving the physical, social and economic environment of deprived areas.
    2. Early intervention and the long term public health benefits of intervening early in the life course particularly for prevention.
    3. Looking at the close interplay between physical and mental health when designing strategies to reduce health inequalities.
    4. The use of fiscal and financial policy instruments to enable deprived populations to live healthier lives.