HC 1048-III Health CommitteeWritten evidence from the Medical Research Council and Economic and Social Research Council (PH 30)

Background

1. The Medical Research Council (MRC) is one of the main agencies through which the UK Government supports medical and clinical research. The MRC is dedicated to improving human health through the best scientific research. The MRC’s work ranges from molecular level science to public health medicine and has led to pioneering discoveries in our understanding of the human body and the diseases which affect us all.

2. The Economic and Social Research Council (ESRC) is the UK’s largest organisation for funding research on economic and social issues. ESRC supports independent, high quality research which has impact on business, the Public Sector and the Voluntary Sector. At any one time, the ESRC supports more than 4,000 researchers and postgraduate students in academic institutions and independent research institutes.

3. The MRC and ESRC are funded by the Department for Business, Innovation and Skills (BIS) and together invest around £908 million per annum (£700 million from MRC and £208 million from ESRC) in research, training and knowledge exchange across a broad spectrum of research areas.

4. This evidence is submitted by the MRC and ESRC and represents the independent views of these two research councils. It does not include or necessarily reflect the views of Research Councils UK or the Department for Business, Innovation and Skills. It aims to address only those areas within the terms of reference of the Committee’s Inquiry which are directly related to the work of the research councils and draws upon the views of research council funded researchers and networks, a list of sources is available in Annex 1.

Main Response

The creation of Public Health England within the Department of Health

5. The ESRC and the MRC welcome the creation of Public Health England and the National Institute for Health (NIHR) School of Public Health, and emphasise the importance of establishing structures that integrate research into services by supporting closer engagement among policymakers, practitioners and researchers.

6. Research is crucial to generating evidence and informing effective policy, and Government needs to embrace and embed research throughout its culture and structures.

7. The implementation of health policies should always be accompanied by a rigorous evaluation of their impact rather than the current approach where evaluation is the exception. In situating Public Health England within the Department of Health it will be important to ensure that the objective evaluation of health policies is not compromised. Public Health England is strongly encouraged to develop guidance which will enable robust evaluation in order to ensure that policies or interventions are effective and cost-effective. Excellent forward planning for evaluation was evident with the introduction of legislation to prohibit smoking at work and in enclosed public places in both England and Scotland (Box 1).

Box 1

Legislation to ban smoking in enclosed public places was implemented in Scotland in March 2006. Evidence from previous research about the harm associated with environmental tobacco smoke, and the success of smoke-free legislation in the Republic of Ireland, were used to make the case in Scotland. Researchers worked closely with policy makers to plan the evaluation plan and ensure that the evidence was used to good effect. Multiple outcomes across several domains were agreed. The evaluation strategy was based on a model linking the ban to short-term, intermediate and long-term outcomes. The evaluation found evidence of changes in smoking culture and behaviour plus measurable improvements in health. At one year the cohort of bar workers reported fewer respiratory and sensory symptoms. A prospective study of admissions to hospital for acute coronary syndrome found a 17% reduction in a ten month period post-legislation, compared with a 4% reduction in acute myocardial infarction (AMI) admissions in England over the same period and a mean annual reduction of 3% in AMIs in Scotland in the 10 years prior to the legislation. A time series analysis of routine admission data found a reduction in asthma hospitalizations in children of 18.2% per year. Prior to the legislation, admissions for asthma among children aged 0–14 had been increasing at a mean rate of 5.2% per year.

Note: The text in Box 1 is taken from the final draft of a forthcoming publication, based on work of the MRC Population Health Sciences Research Network.

8. The creation of the NIHR School of Public Health is a welcome addition to increasing the evidence base in public health and has the potential to improve the collation of evidence and increase its translation into health policy and practice. It will be important to ensure that the School complements, and communicates with, existing centres of excellence in public health research which have considerable strength and expertise in the field (eg UK Clinical Research Collaboration Public Health Centres of Excellence).

9. A better understanding by practitioners of how research can be applied in practice would be welcomed. This could be achieved through greater integration between academic researchers and service providers and practitioners. Public Health England and the NIHR School of Public Health will need to work closely with the Faculty of Public Health to bridge this divide.

10. Routes for the input of independent evidence to Public Health England are essential, and transparency around those routes is necessary.

11. The MRC and ESRC support the use of standards for the collection and storage of health and other public sector data (eg education or housing) in secure and well curated repositories. Public Health England will need to ensure that there are structures in place to collect, maintain and safeguard high-quality data which is accessible for both administrative and research purposes.

12. The burden of research governance is heavy, especially for large-scale population studies, and Public Health England should be closely involved in the process of streamlining research governance, and developing procedures proportional to the risks incurred by research participants, as recommended by the recent Academy of Medical Sciences report on regulation and governance.

13. The Department of Health is not the only department developing and implementing policy which impacts upon public health. A significant role is played by other departments (eg Department for Transport, Department for Environment, Food and Rural Affairs, Department for Culture, Media and Sport) which should use evidence in public health to inform their strategies and priorities. These departments need to be active participants in developing and evaluating policies and interventions which may affect health, in areas such as taxation (eg on alcohol and tobacco), the environment, environmental health, leisure, transport, planning, children’s services, housing and social care. Appropriate structures and active channels of communication are required across Government to ensure join-up across departments whose activities may impact public health.

14. The proposal, formalised within the recent Department of Health strategy for public health in England Healthy Lives, Healthy People, to provide resources which support interventions undergoing research outside the NHS, must not be lost by a potential focus within the Department on the NHS setting or the clinical environment.

The abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse

15. The Health Protection Agency (HPA) is widely recognised for excellent research and should maintain its independent status and research capability in order to best protect the health of the public. If the HPA becomes embedded in Public Health England it will be difficult to demonstrate and maintain its crucial independent role. The HPA has received strategic funds from the MRC, ESRC and others to carry out collaborative research in priority areas. By transferring HPA to Public Health England, HPA researchers would become ineligible for funding by the research councils, thereby impacting upon opportunities to conduct collaborative research in areas of major public health concern.

16. Likewise, it is vital that the work of the National Treatment Agency for Substance Misuse is continued. Effective alternatives would need to be implemented to replace the functions of the Agency if it were abolished. Such provision should be led by professionals in substance misuse treatment, and be guided by the latest research findings in this field.

The public health role of the Secretary of State

17. The increased commitment to Public Health by the Secretary of State is welcomed. There is some concern from the research community that there may be over reliance in the Department of Health Strategy for Public Health on individual behavioural change and local initiatives delivering services.

The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

18. Strengthening the role of local authorities recognises that health is influenced by a wide and diverse range factors beyond health services (eg urban design, transport or housing) and is a positive step. However, to ensure that the health impacts of policies are fully considered, each Director of Public Health must sit on a Local Authority Executive Board alongside colleagues representing others interests (eg urban design, transport or housing).

19. Directors of Public Health should have an understanding of research and evidence based practice. Ideally Directors should be accredited Public Health consultants. They should be adequately resourced to fulfil public health functions including advising GP commissioning.

20. Local government and local communities are central to the Department of Health’s public health strategy yet they have limited experience in commissioning and running health services and adopting research outcomes. As they take on their commissioning role, local authorities will need to be develop a research-aware culture to ensure services and policies are evidence based where possible, and can be robustly evaluated.

21. For services to be effectively integrated it will be important that GP consortia have a defined population within an area that aligns with the local authority boundaries.

22. Joint Strategic Needs Assessments are a welcome development but they must be seen to inform GP commissioning as well as local authorities.

23. The proposed role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies in bringing health and care provision together within their local areas to support vulnerable members of the community is to be commended. However, it is important that these bodies are equipped to take full advantage of research findings across both disciplines.

The arrangements for public health involvement in the commissioning of NHS services

24. Primary care professionals can play a critical role in primary and secondary prevention by providing guidance, brief interventions and referral to, or commissioning of, targeted services (eg weight management). It is important therefore that GPs and GP practices, and also pharmacies, understand and employ the best mechanisms to address prevention in their populations.

25. Some health professionals making commissioning decisions for NHS services may have limited understanding of public health. Arrangements for public health involvement in the commissioning of NHS services are necessary as they are a key part of public health alongside health protection and improvement. It is essential that the views of the Directors of Public Health and other champions of population health are fully considered in commissioning decisions.

26. Government will need to ensure the means by which patient data from GP practices is accessible to other GPs and to the research community, in order to monitor ill health and provide the basis for research evidence to underpin policy.

27. The UK has a number of clinical networks including the MRC General Practice Research Framework (GPRF), UK Clinical Research Network (UKCRN), NIHR Primary Care Research Network (PCRN), regional networks in England and counterparts in Scotland, Wales and Northern Ireland. The MRC GPRF is a UK-wide network of general practices that, over the last three decades, has been involved in clinical trials, epidemiology and health services research. An example of high-impact research involving primary care professionals, facilitated and supported by the GPRF, is indicated in Box 2.

Box 2

FLUWATCH is a community study of behavioural and biological determinants of transmission to inform seasonal and pandemic planning. Funded by the MRC, FLUWATCH has been a very successful collaboration between the General Practice Research Framework (GPRF) and University College London, the Health Protection Agency and MRC Human Immunology Unit at Oxford. The study was funded in response to the MRC pre-pandemic call for influenza research in 2006 and recruited a cohort of over 2,000 individuals. The study has informed our understanding of the epidemiology and transmission dynamics of seasonal influenza as well as the role of prior T cell immunity in development of infection.

Key FLUWATCH findings demonstrate the value of an existing community cohort in studying influenza. In order to provide prompt answers in a pandemic, however, much larger populations must be examined, with “real time” processing of specimens, so that sufficient cases accrue and are analysed in the early phase of the pandemic to inform action in later phases. In June/July 2009, three to four months after the WHO reported the emergence of a new A/H1N1 strain of influenza, the GPRF facilitated collaboration of the existing FLUWATCH research group and the MRC Centre for Outbreaks Analysis and Modelling. As a result, a new FLUWATCH Pandemic Consortium was created with £2.1 million from MRC and Wellcome Trust to undertake a prospective cohort study designed to recruit 10,000 people in general practice. This cohort has described the clinical course of infection and the effectiveness of clinical counter measures and the epidemiological characteristics of the A/H1N1 pandemic. It has monitored changes in population behaviour through the pandemic, providing a greater understanding of immunity to infection (particular T cell), and informed the ongoing vaccination policy.

28. The National Institute for Clinical Excellence (NICE) makes a major contribution to public health intelligence through its reports on specific topics such as preventing heart disease and encouraging physical activity, by providing more general guidance on research methods, and by identifying research priorities. It is critical that NICE retains its central role in providing impartial, independent, expert appraisals of the public health evidence base. How this role will dovetail with that of the annual evidence reviews, proposed in the recent Department of Health strategy for public health, requires careful consideration to ensure transparency and independence is maintained in the provision of evidence.

The future of the Public Health Observatories

29. The MRC and ESRC support the collection and storage of high quality health and other public sector data in well maintained repositories accessible for administrative and research purposes. The Public Health Observatories play an important role in the provision of information and data on people’s health and health care for practitioners, policy makers and the wider community. It is vital that data standards for the collection, storage and security of health and other public sector data are maintained if functions of the Observatories are transferred.

The arrangements for funding public health services (including the Health Premium)

30. The ESRC supports the principle of targeting specific funding for public health to the poorest areas with the worst health outcomes, so long as this is not detrimental to other, slightly less poor areas whose health outcomes are only marginally better. We support the recommendations outlined in Chapters 4 and 5 of the Marmot Review Fair Society, Healthy Lives, which call for an inclusive approach which reduces the gradient in health inequalities across society.

The future of the public health workforce (including the regulation of public health professionals)

31. The Department of Health strategy for public health does not adequately address public health training or public health as a profession. It remains unclear how training and regulation will work with the Directors of Public Health in local authorities, for communicable disease and environmental health in Public Health England and for others involved in commissioning. This lack of clarity is causing anxiety among the profession and will inevitably lead to staff losses.

How the Government is responding to the Marmot Review on health inequalities

32. The Marmot Review is acknowledged in the Department of Health strategy for public health. The strategy highlights the need to reduce health inequalities through a life course approach as advocated by the Marmot Review. The MRC and ESRC commend this focus and emphasize the importance of research in generating evidence to inform and evaluate policies underpinning this goal.

33. However, the practical challenges of reducing health inequalities and implementing research evidence into policy and practice are not insignificant. Various measures designed to improve the integration of research with policy and practice have been highlighted above and should be taken into account in the new Public Health England structures.

34. A key message from the Marmot Review is that health inequalities result from social inequalities. The ESRC notes that if this point is accepted, it follows that, in our unequal society, a narrow focus on attempts to change the health behaviours of individuals without taking adequate account of their differing social circumstances is unlikely to be successful.

June 2011

Annex 1

SOURCES OF EVIDENCE FOR THE RESPONSE

1. Wellcome Trust/MRC/ESRC workshop “Healthy Lives, Healthy People” (1/03/11).

2. MRC Population Health Sciences Group (PHSG), which includes individuals from the following organisations:

University of Glasgow;

University of Oxford;

University of East Anglia;

University College London;

London School of Hygiene & Tropical Medicine;

University of York;

Erasmus MC, The Netherlands;

INSERM, France;

MRC/CSO Scottish Collaboration for Public Health Research and Policy;

MRC Lifecourse Epidemiology Unit;

MRC Epidemiology Unit; and

MRC/CSO Social and Public Health Sciences Unit.

3. MRC Population Health Sciences Research Network (PHSRN), which includes individuals from the following organisations.

MRC Biostatistics Unit;

MRC Centre for Causal Analyses in Translational Epidemiology;

MRC Centre for Cognitive Ageing and Cognitive Epidemiology;

MRC Centre of Epidemiology for Child Health;

MRC Centre for Nutritional Epidemiology in Cancer Prevention and Survival;

MRC Clinical Trials Service Unit and Epidemiological Studies Unit;

MRC Clinical Trials Unit;

MRC Lifecourse Epidemiology Unit;

MRC Epidemiology Unit;

MRC General Practice Research Framework;

MRC Human Nutrition Research;

MRC/CSO Social and Public Health Sciences Unit; and

MRC Unit for Lifelong Health and Ageing.

Prepared 28th November 2011