HC 1048-III Health CommitteeWritten evidence from the National Institute for Health and Clinical Excellence (PH 139)

Introduction

1. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. NICE’s public health guidance is the most systematic and thorough appraisal of the evidence of the effectiveness and cost effectiveness of public health actions and interventions in the world. Whatever the shape of the new public health system, it is paramount that it has access to and uses the best available evidence. This is something NICE can provide.

2. NICE’s public health programme produces guidance and advice for the NHS, local government and other sectors, with recommendations about populations, communities, groups and individuals on actions, interventions, activities, policies and strategies that can help prevent disease or protect and improve health. All recommendations, standards and services are developed in consultation with independent advisory committees that include experts and members of the public, who examine the best available evidence of effectiveness (does it work?) and cost effectiveness (is it good value for money?).

3. NICE also provides access to a range of public health evidence, including NICE guidance, through NHS Evidence. This service incorporates the resources provided by the National Library of Public Health, and provides public health professionals with a comprehensive set of evidence to inform population planning and commissioning.

4. We welcome the opportunity to contribute to this inquiry, prompted by Government proposals for major changes to the organisation of public health services, as part of its wider plans for reform of the NHS. We have submitted evidence to Government consultations on the Health and Social Care Bill currently progressing through Parliament, and on the White Paper Healthy Lives, Healthy People: Our Strategy For Public Health In England.

5. The changes to the public health system announced in the White Paper mean that NICE will maintain the rigorous, evidence-based approach that enables it to provide authoritative, independent advice. In the proposed new system, it is vital that local government and NHS commissioners have easy access to evidence-based solutions. Existing NICE public health guidance (or derivatives of it) provides, or potentially provides such access. We are taking this opportunity to look at how we might adapt our products, communications, and range of engagement activities to meet the needs of the new circumstances.

6. The recently published Health and Social Care Bill also sets out a role for NICE in preparing Quality Standards for public health services and giving advice, guidance, information and recommendations on matters connected with public health services (clauses 218 and 221).

7. The White Paper states that NICE will work to specific commissions from Public Health England to add maximum value by providing authoritative, independent advice on the evidence of effectiveness and cost effectiveness of public health interventions (section 4.87). It also refers to NICE’s work on the relative cost effectiveness of different interventions as the basis for Public Health England’s function of developing intelligence to support directors of public health in commissioning local services. The White Paper also refers to the work NICE has undertaken on the return on investment of public health interventions.

8. The proposals outlined in both the Bill and the White Paper present an unprecedented opportunity to refocus public health efforts, with local government at the heart of these new arrangements.

Public Health and the Role of NICE Guidance and Advice

9. There are three broad domains of public health: health improvement, health protection and health services. NICE has expertise and guidance covering all three domains, from recommendations on increasing physical activity in populations to work in development on identifying and managing tuberculosis among hard-to-reach groups. Rather than a summary of high-level messages on public health topics, our guidance is focused on using the evidence base to tease out the intricacies within each topic, identifying issues such as groups to target, inequalities to address, and providing methods for costing the impact of interventions so that they can be adapted and used at a local level.

10. The White Paper outlines how the new public health system will involve Public Health England, local government and NHS commissioning supporting a proposed public health outcomes framework and a “health premium”, which will incentivise local government and communities to improve health and reduce inequalities, while leaving them free to decide how best to do this, in line with local needs (section 2.8).

11. For local authorities, being able to demonstrate improved outcomes will be critical, not just in improving people’s lives, but in attracting the health premium incentive. Public health advice and guidance from NICE will therefore play a key role in enabling these organisations to deliver improvements in public health. NICE’s expertise lies in examining and synthesising the current evidence base, and we have developed unrivalled expertise in the challenges associated with constructing the evidence base.

12. NICE public health guidance covers all the topic areas identified in the White Paper, apart from emergency preparedness, pandemic flu and excess winter deaths—topics on which NICE would be willing and able to develop guidance and advice. There are now 35 published pieces of guidance, much of which relates to fundamental public health topics such as tobacco, alcohol, diet and obesity, physical activity, mental health and child health.

13. The model used in public health in NICE has taken a life-course approach, which is also central to the White Paper. We provided support for the WHO Commission on the Social Determinants of Health, as one of the supporting evidence hubs concerned with Measurement, Evidence and Knowledge which has been influential (through the work of Sir Michael Marmot) in the White Paper’s focus on the wider determinants. Our existing product range therefore aligns with this White Paper priority.

14. We are taking the opportunity to review the guidance and support for putting guidance into practice so that we can ensure that, at the point when local government takes the lead in public health, our guidance provides practical assistance to local authorities as they seek to make progress against elements of the outcomes framework; helps Directors of Public Health in their duties of promoting health and well-being; and supports health service commissioning.

NICE Quality Standards

15. The Health and Social Care Bill refers to quality standards for public health. NICE has already started to consider how quality standards could be used in the public health arena. Public health quality standards would be able to:

(a)support the public health outcomes framework by defining high standards for public health interventions and processes;

(b)support progress on outcomes by providing a package of information, including indicators, which can be a tool for national and local commissioners and the range of public health service providers;

(c)offer benchmarks against which local authorities, NHS commissioners, other local agencies and the public can assess progress on priorities—particularly priorities related to the premium;

(d)align with the GP Quality and Outcomes Framework by supporting primary and secondary prevention indicators;

(e)highlight the contribution of public health interventions to NHS and adult social care outcomes, support service integration where appropriate, and clarify the role of public health on care pathways that cross the boundaries of clinical care, social care, and prevention and health improvement and;

(f)Fit with the White Paper’s aims of devolving responsibility, including responsibility for prioritisation based on local need. In the case of local government, they would be sensitive to the local democratic mandate and the idea of localism.

16. In the same way that our quality standards on clinical topics are produced, public health quality standards would be based on evidence, building on the platform of existing or future NICE guidance and/or NICE advice products, but also taking account of other good quality evidence, including resources available through NHS Evidence. They could take three main forms:

(a)As a preventative dimension to any clinical pathway and relevant NICE clinical quality standards. COPD and diabetes are two good examples of where a preventative aspect to the clinical pathway would fit well.

(b)On key public health topics for the NHS on tobacco, alcohol, obesity and physical activity. This would ensure that those areas currently the responsibility of the NHS (eg alcohol nurses working in A&E Departments) remain an NHS priority when public health responsibilities transfer to local authorities. There is an opportunity to develop integrated packages around each of these areas, something which NICE is already trialling with NICE Pathways (see below).

(c)On topics that apply to local government where standards would be helpful, eg contraceptive services, smoking cessation, early years services, and the wellbeing of looked after children.

Public Health and the Evidence Base

17. With the changes in public health structures there is also an opportunity to take a fresh look at the opportunities presented by new ways of using the evidence base, particularly with respect to how evidence can be collated and accessed digitally. Evidence-based medicine has made a major impact in the clinical arena over the last three decades, and there is an opportunity to further develop evidence-based public health. However, this will need to move beyond systematic reviews to harvesting the potential benefits of digital, rather than paper-based ways of cutting into and extracting information. If the evidence base is conceived of as an evolving digital pool rather than an electronic way of representing paper documents, potentially it provides a more powerful and smarter way of doing things, which can be better tailored to different audiences, whether local government officer or members, public health expert or clinician. As part of a wider digital transformation strategy, NICE has been pioneering the following:

(a)NHS Evidence, managed by NICE, a service that enables access to authoritative clinical and non-clinical evidence and best practice through a web-based portal. It helps people from across the NHS, public health and social care sectors to make better decisions as a result. An enhanced service was launched in May 2011 and includes access to the former National Library for Public Health.

(b)NICE Pathways is a new interactive tool which provides online access to NICE recommendations, including public health topics such as smoking, diet and physical activity. NICE Pathways allows links to be created between these different public health topics, and is the first time access to public health evidence has been made available in this way. The aim is to make information available based on “setting” (school, workplace, etc.) or “topic” (smoking, diet, etc).

(c)Opportunities to use the latest technology to provide access to the public health evidence base alongside relevant data and intelligence. Effective syndication of public health evidence to third party providers of data and statistics will provide an efficient resource for Public Health England, to inform population planning and resource allocation. The development of this work is being informed by an external Public Health Information Reference Group, which is providing advice on the information requirements that should sit alongside NICE Pathways, including cost information and support for prioritising public health interventions.

Public Health Concepts

18. It is our view that there has been an overemphasis on structures for public health in much of the discussion about the White Paper and the Bill, with perhaps not as much focus on the concepts behind the proposals, which themselves deserve further analysis.

19. The simple view of public health is that is composed of two broad approaches:

(a)individualistic focusing on educating /informing /counselling people to change their behaviour;

(b)population focussing on the legislative/regulatory route (for example through laws on seatbelt use or banning smoking in public places and clean air).

20. Both methods have had some successes, but have their drawbacks. In a), this process appeals to people’s rational behaviour (by demonstrating the consequences of smoking/lack of exercise/unhealthy diets, people will change) but fails to take into account the non-rational side of human nature. For b), there are clearly limits to how much of human life can be regulated. In free societies such as ours, it becomes difficult to avoid the “nanny state” labelling of such activities.

21. The alternative approach to these two positions at opposite ends of the spectrum is one that involves an understanding of how human health evolves from a combination of behaviour and habits, and the interaction between human agency and social structures. It is this approach that NICE has taken in producing public health guidance. The White Paper embraces the NICE approach by speaking a new public health language, advocating an approach that also draws on a tradition of community development/empowerment approaches. Instead of individual behaviour change versus population approaches as polar opposites, a self-governing and self-regulating society is envisaged in which local action by individuals, communities, associations and businesses generate and protect good health.

22. These approaches are ones that NICE has adopted, for example through its work on services and environmental changes (by providing convenient and safe ways for people to be physically active) and providing better access to a range of health and community services, particularly for disadvantaged groups. We have advocated population-based approaches which are not legislative but about identifying those who are most at risk and delivering tailored support. We have also produced work that is concerned with reducing the risks of ill health that arise from the actions of others, such as drink driving.

23. Health in this view is the outcome of social processes which flow naturally out of the activities of institutions and individuals. To help steer or nudge these processes, evidence-based public health activities focus on social norms and community networks. Local action leads to the establishment and diffusion of health-beneficial good practice and social integration. Resilience develops and flourishes in these circumstances, in the same way as the opposites—vulnerability and exposure to excess risk—are endemic in the absence of a well integrated local social system. NICE’s public health activities have been structured around these ideas and we look forward to continuing to develop and refine our guidance and processes to best support the new system.

June 2011