Evidence based public health leadership.

Leading Health and Wellbeing from Transition to Transformation, the Law

Society, London, 26th June 2013.

Professor Mike Kelly, Director of the Centre of Public Health, NICE and the Institute of Public Health, University of Cambridge.

Evidence based medicine, evidence based public health and evidence based

leadership

• The role of NICE

• The role of evidence

• The new environment

• Leadership and evidence

NICE

The National Institute for Health and Care Excellence (NICE) is the independent organisation in the UK responsible for providing evidence based national guidance to Local Authorities, the NHS and the wider public health community on the promotion of good health and the

prevention and treatment of ill health.

The task for pubic health at NICE from 2005

• To apply the principles of Evidence Based Medicine (EBM) to public health.

The task from 2005

• To apply the principles of EBM to public health.

• To develop the methods to do so.

Why is this important?

The legacy of Archie Cochrane

Effectiveness and Efficiency (1972)

• Do we know whether intervention x for public health problem y is effective?

• Do we know whether intervention x for public health problem y is effective?

• How do we know it is effective?

• Do we know whether intervention x for public health problem y is effective?

• How do we know it is effective? • How do we know whether it is more or less effective than

intervention z?

• Do we know whether intervention x for public health problem y is effective?

• How do we know it is effective? • How do we know whether it is more or less effective than

intervention z? • On what basis do we make that judgement of effectiveness?

• Do we know whether intervention x for public health problem y is effective?

• How do we know it is effective? • How do we know whether it is more or less effective than

intervention z? • On what basis do we make that judgement of effectiveness? • Do we know what it costs? And is it cost effective?

• Do we know whether intervention x for public health problem y is effective?

• How do we know it is effective? • How do we know whether it is more or less effective than

intervention z? • On what basis do we make that judgement of effectiveness? • Do we know what it costs? And is it cost effective? • If it is not cost effective, why is it still being used?

• Do we know whether intervention x for public health problem y is effective?

• How do we know it is effective? • How do we know whether it is more or less effective than

intervention z? • On what basis do we make that judgement of effectiveness? • Do we know what it costs? And is it cost effective? • If it is not cost effective, why is it still being used? • What are the dangers posed to the public of interventions and

actions about which we are scientifically uncertain?

• Do we know whether intervention x for public health problem y is effective?

• How do we know it is effective? • How do we know whether it is more or less effective than

intervention z? • On what basis do we make that judgement of effectiveness? • Do we know what it costs? And is it cost effective? • If it is not cost effective, why is it still being used? • What are the dangers posed to the public of interventions and

actions about which we are scientifically uncertain?• Are the interventions dangerous? Why are we using potentially

dangerous or worthless interventions?

• Do we know whether intervention x for public health problem y is effective?

• How do we know it is effective? • How do we know whether it is more or less effective than intervention

z? • On what basis do we make that judgement of effectiveness? • Do we know what it costs? And is it cost effective? • If it is not cost effective, why is it still being used? • What are the dangers posed to the public of interventions and actions

about which we are scientifically uncertain?• Are the interventions dangerous? Why are we using potentially

dangerous or worthless interventions?• The problem of equipoise.

Some popular ideas but where the evidence is far from convincing.

• Peer support approaches• Social marketing• Stages of change models of behaviour change• Financial incentives• Nudge theory

The implementation gap

• There is an extensive evidence base about what works and about what is cost effective.

• The failure of the last two decades has been not to implement that which is known in favour of doing gimmicks, bright ideas, common sense, rolling out pilots, vision statements, etc. etc.

Not a new problem: some historical examples.

• British naval policy pre 1914• Foot and mouth disease• Raising of the school leaving age• Abolition of grammar schools• Creation of academies• Nationalisation of the steel industry• Etc.etc.

Some evidence to policy successes

• The breathalyser and drink driving legislation• Set belt legislation• The smoking ban• The response to HIV AIDs

The pillars of NICE’s work

• Comprehensive evidence base

• Detailed appraisal of the evidence

• Expert input

• Patient and carer involvement and community engagement.

• Independent advisory committees

• Genuine consultation

• Regular review

• Open and transparent process.

Assessing Cost Effectiveness

Probability of rejection

Cost per QALY (£K)

x XX XX

10 20 30 40 50

0

1

The health gradient

Health state

Social statusHi Lo

Lo

Hi

The health gradient

Health state

Social statusHi Lo

Lo

Hi

The health gradient

Health state

Social statusHi Lo

Lo

Hi

Shifting the health gradient

Health state

Social statusHi Lo

Lo

Hi

Public Health and Local Authorities.

Key issues

• Politics• Evidence• Independence• Budgets and finance

Key places

• Health and Well-being Boards.

• Scrutiny Committees

• Environmental Health

• Trading Standards

• Planning

• Education

• Children’s services

• Adult Services

• Leisure and recreation

NICE Local Government Public Health Briefings

• to raise awareness among elected members and officers of public health evidence;

• to demonstrate the potential role of NICE evidence and guidance as the basis for solutions to public health issues and problems at local level;

• to provide summaries of NICE evidence based recommendations in forms of direct use and relevance to local government.

• to meet the needs of local government as they prepare for the transition to assume public health responsibilities after April 1st 2013.

• will be derived from the existing Guidance.

Published

• NICE (2012) Tobacco http://publications.nice.org.uk/tobacco-phb1

 • NICE (2012) Workplace Health

http://publications.nice.org.uk/workplace-health-phb2

 • NICE (2012) Physical Activity

http://publications.nice.org.uk/physical-activity-phb3

 • NICE (2012) Health inequalities and population health,

http://publications.nice.org.uk/health-inequalities-and-population-health-phb4

• NICE (2012) NICE guidance and public health outcomes, http://publications.nice.org.uk/nice-guidance-and-public-health-outcomes-phb5

 • NICE (2012) Alcohol, http://publications.nice.org.uk/alcohol-phb6

 • NICE (2013) Behaviour Change

http://publications.nice.org.uk/behaviour-change-phb7

• NICE (2013) Walking and Cycling http://publications.nice.org.uk/walking-and-cycling-phb8

• NICE(2013) Preventing obesity and helping people to manage their weight

• http://publications.nice.org.uk/preventing-obesity-and-helping-people-to-manage-their-weight-phb9

•  

We are working on now:-

• Health economics and return on investment• Contraceptive Services• Sexual health services, • Health checks, • Young people’s well being• Drugs• Hard to reach communities• Looked after children • TB • Children at high risk

NICE local government public health briefings

www.nice.org.uk/localgovernment

NICE local government public health briefings

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Conclusion

The Mintzberg Dilemma

The Jowett Dilemma

“First come I; my name is Jowett.

There’s no knowledge but I know it.

I am master of this college:

What I don’t know isn’t knowledge.”

The Masque of Balliol

Revd. H.C. Beeching

Institutional resistance

• Change only possible at the margin.

• Resources.

• Habitual decision making.

• Power

Getting public health evidence into the DNA of

local authorities.