HC 1048-III Health CommitteeWritten evidence from The Campaign Company (PH 107)


Unlike controversies surrounding other NHS reforms, the proposals for Public Health seem to have secured broad professional and political consensus. In order to make them more effective we would argue:

Broad autonomy on use of local resources subject to full transparency.

Strengthened Health and Well-Being Boards to deliver this.

We support the broad structures proposed, but would argue the following areas need to be addressed in public health if the current proposals are to be seen as just a reorganisation of people and a series of processes divorced from the challenges of people in communities who may face multiple challenges related to social determinants of health. We thus argue for the following:

Having a strategy to tackle motivation and not just ability.

Communicating to people’s emotions and not just convey facts.

Effective segmentation that is not just about “how” but also “why”.

Targeting behaviour change strategies not just on patients or the wider population, but also on key professionals such as GPs.

Many people will respond in process terms because their values are ones that have high regard to addressing “ability” and conveying objective “information”. However when it comes to the client groups that are supposed to benefit from reducing health inequalities the fundamental issues in behavioural terms are around addressing “motivation” and doing this through authentic emotionally resonant communications relevant to their values.

The paper below explains that case in more detail after covering some initial practicalities

Transition Issues

1. The current lack of any formal outcomes after the abolition of targets is leading to a dangerous two year hiatus at a time when PCTs and their staff are somewhat inwardly focused. Whilst the recent publication of “Changing Behaviour, Improving Outcomes: A new social marketing strategy for public health” is welcome the Department of Health (DH) needs to issue some interim guidance is issued to make it clear exactly what the public health strategy is for the 2011-13 period.

Public Health Outcomes Framework

2. In order that the Outcomes Framework enables local partnerships to work together on health and wellbeing priorities, there will be a requirement to make it local and ensure incentives are big enough to drive local innovation. Perhaps the process should be to develop a “locally agreed JSNA” that first and foremost represents local priorities and that is signed off after negotiation with Public Health England, so that the programme adopted is bottom up and not top down.

3. The Outcome Framework indicators promote a life-course approach to public health, which the proposed “Domains” seem to allow for. However this assumes that a life-course approach is the principal approach to apply. The life course of a person in a safety, security and sustenance driven environment reinforced by social networks is going to be very different to one with very different values and more pro-social networks. We address this issue in more detail below.

4. Almost all the proposed indicators are “Big Government” and about the role of professionals. Very few could be described as “Big Society”. Indeed the only two that did not require automatic leadership by paid health professionals are:

Cycling participation.

Social Connectedness.

5. Some might argue that other indicators do at least require co-production by individuals with professionals to achieve those outcomes, however the challenge is that if these are to be achieved with limited resources how does one prioritise this & identify communities with values that are least likely to respond to behavioural change, rather than spread proposed interventions too thin.

6. What the proposed Outcomes currently seem to miss is that many of the separately recorded indicators all involve challenges involving exactly the same communities and target groups. Perhaps a more effective approach is engaging with lifestyles holistically and not produce yet another set of separate strategies for individual problems which are likely to substantially overlap at a time when money is tight?

7. Behaviour change theory tells us that a lot has been invested in ability. In other words “bring the horse to water”, or more likely in the toughest “Nudged” cases “bring the water to the horse”. Yet many of those behavioural approaches also make the point that one has address motivation too. In that case “get the horse to want to drink”!

8. A modern approach to this needs to include targeted values segmentation, network mapping, and using a range of behavioural and influence techniques to build and reinforce new social norms. These cannot simply be about presenting objective public health facts that people sit in workshops and consider in a rational way. We also need to frame things in such a way as to address the needs, emotions and values of a targeted community in order to motivate it!

9. Thus the Public Health Outcome Framework should not be seen as just a menu of indicators for practitioners to make short-list of, but also an opportunity to debate the most effective ways we can deliver behaviour change for a pro-social benefit.

10. There is also a danger that the neatness of alignment of the Outcomes Framework approach NHS, Adult Social Care and Public Health means that it is designed for ease of reporting to Parliament. The use of Domains are a very good approach but they should be looked at first of all in terms of their usability in the field they are being applied to. Then linkages should be identified. This is bottom up approach is likely to be more realistic than the current top down approach, whilst still retaining transparency in what is finally agreed.

11. In term of developing relevant indicators two things are important to consider.

12. Firstly, indicators that are sensitive to local intervention rather than big picture national indicators. The Local Authorities and Health Observatories will collect this big picture data anyway and, assuming open source availability leads to new suppliers of interpreted data, this information will already be available. In other words, make them:

More locally influenceable at local authority level.

Make them more influenceable by the public rather than just through the activity of professionals.

13. Thus in terms of incentivising indicators the key ones are those that a local authority can realistically be seen to influence in a given timescale, rather than the more national indicators.

14. Secondly, the levels of self-efficacy and motivation within communities is vital. This will tell one much about how much effort is required in each community and will give you more realistic information so as to inform distribution of the Health premium. This is the approach commercial marketers use, yet DH so far seems committed to fighting these pervasive influences in the community only with information that one already has by having a copy of the Marmot Review. The measurement of subjective experience is being addressed in a broader sense with the consultation by the Cabinet Office over Indicators of National Happiness. DH should link to that with a measurement of levels of self-efficacy and motivation in order for DH priorities to link better to wider government objectives around Happiness and the Big Society. It would also provide the data required by the Cabinet Office Behavioural Insight Team to measure interventions in line with behavioural projects such as “Mindspace”, which would increase the value of Public Health to other Government objectives. There are various approaches to segmentation that allow for the objective measurement of subjective outlooks that would enable a baseline to be quickly developed. If this is seen as radical for full roll-out at this stage, then DH should announce "pilot indicators" such as self-efficacy in order to then early on under the new arrangements be able to evaluate new indicators within the first two years of it, to create some potential for alternative indicator sets in preparation for when the initial Outcomes Framework is evaluated & reviewed.

Health Premium

15. The only way the health premium will work to seriously incentivise organisations and communities to reduce inequalities is through big incentives. The lesson of behavioural economics is surely that the incentive should not just be a sop for the sake of it, but designed to make a difference. DH should conduct a review of the research into incentives as well as conduct pilots in the remaining lifetime of PCTs run services to test what really works. In addition can resources here be used as a revenue stream to enable organisations to seek additional resources through Social Impact Bonds to seek to deliver locally agreed outcomes and if not where might that apply in a Public Health context or is that being discounted?

16. We would argue that segmentation that takes account not just the how and where of public health challenges but also the “why” in terms of “motivational values” is important as some segments of the population will be far less responsive to positive behavioural change than others and this has now been measured for a long period. Funding and the Health Premium should recognise and incentivise progress in those areas which are “tougher nuts to crack” and inequality, low community resilience and poor social capital is more deeply ingrained. This is likely to be the only way to motivate organisations to motivate people in those areas over a number of years.

17. DH has suggested linking access to growth in health improvement budgets to progress on elements of the Public Health Outcomes Framework to provide an incentive mechanism. However this sounds too much like a tragedy of the commons problem. Whilst professionals are well-meaning, there is a danger that it will be then be “no-one’s fault” if there is not progress. We should incentivise any local progress and use that bottom up approach to create innovation and transferability to other places. Some localities will be much harder to make progress due to certain values and social norms reinforced in those communities by the nature of their current social networks. Measurement of this challenge is important in order to inform the basket of indicators that determine the Premium and the segmentation has long existed to do it.

Taking forwards the Marmot Review: Measuring and addressing “Motivation” in public health

18. The Cabinet Office’s own “Mindspace” report draws from current behavioural theory. What this tells us is that one cannot achieve a successful behavioural outcome without addressing two questions for the individual you are targeting.. They are:

Ability: “Do I have the ability to continue, start, adapt or stop this behaviour”? eg skills, tools, finance, time, physical and mental effort, knowledge and physical access.

Motivation: “What’s in it for me, or for people like me, to start, adapt or stop this behaviour?”

19. Public Health strategies tend to aim to focus on the first question - Ability. This approach relates to tackling and supporting the ability of people to utilise the service or behave in the desired way by making the information as accessible as possible. In other words much of the effort has gone into building mechanisms that enable people to access information without understanding who will use the information and how its use varies between individuals. Understanding how different individuals are likely to respond will make communications more effective, achieve better outcomes and be a better use of resources. Addressing motivation is likely to be far less expensive than all the resources poured into tackling ability.

20. The Department of Business and Innovation and Skills recently commissioned as part of its "Sciencewise Expert Resources Centre" a report by the well-known environmental campaigner Chris Rose entitled "Consultation and Communication in relation to motivational needs". Since with public health behaviour change we are increasingly recognising the importance of motivation, it is surprising that DH is not drawing from that knowledge base too. Segmentation based on geo-demographics such as MOSAIC and ACORN tell you “how” people behave and we now have lots of data at each Health Observatory telling us “where” and to what intensity. However when it comes to motivation we need to understand “why” people behave. That requires as Chris Rose argues an understanding of the values in a given community. From our research and the work we are now commencing with the RSA – who are doing pioneering work on social networks - we believe this is often reinforced by the social networks and types of social capital that people have.

21. Values are one’s judgements about what is important in life and the lens that you look through when you view and try to make sense of the world. 

22. Our values are derived from our unconscious motivation to satisfy a range of needs as we navigate our way through day to day life. A need is something that is necessary for us to meet if we want to live a physically and emotionally healthy life.

23. Needs can be objective and physical, such as food and water, or they can be subjective and psychological, such as the need for security or self-esteem.

24. The key thing to understand is that it is from our “dominant need” that our values – what is most important to us - are derived. And when faced with a decision it is these values that provide the unconscious “frame” that kicks in and sets the context before we actually take action.

25. Once we understand values, we understand what makes people tick. And we can start to understand how they might perceive services, how to deliver them in an in an empathetic way that matches their values and, crucially, how to motivate them to do things.

26. UK based values segmentation data is based on 37 years of data collected via the British Values Survey of 8,500 people in a nationally representative survey. The information gathered contributes to the global academic network that has built the World Values Survey, led by Professor Shalom Schwarz. The resulting segmentation gives us three principal values groups:

Sustenance Driven “Settlers”: motivated by the core needs of safety, security and belonging. Home, family and immediate neighbourhood are important, and the wider world often feels threatening. Change is often seen as negative.

Outer Directed “Prospectors”: motivated by the need for self-esteem and the esteem of others. Job progression, money and social status are important to them and although usually optimistic, they can worry for example about their status or they perceive declining quality of an environment.

Inner directed “Pioneers”: motivated by ideas, aesthetics and personal development. Interested in new information and often the initiators of change. They tend to have large social networks, but individuality is more important than following the crowd.

27. Applying these three core values groups help us understand how people make sense of the world, what motivates them to act, and therefore means we are able to more effectively craft information and messages – whether verbal or written - which resonate with these motivations.

Developing a New Role for GPs and GP Practices in Promoting Public Health

28. The King’s Fund Paper “A pro-active approach. Health Promotion and Ill-health prevention” covers many of the areas of this issue and we recommend it is read as part of this inquiry. Hopefully the King’s Fund themselves will make a submission along these lines.

29. QIPP incentives are likely to be too low in many areas which contain a minority of deprived communities and thus behaviour change strategies may need to be addressed towards GPs behaviour rather than just their patients! The 1990 contract increased GP involvement in preventative medicine from 5% to 25% with GPs enquiring more of patients. However GPs were not drawn beyond the surgery door and still focused on clinical duties.

30. Policy initiatives have sought to increase the advice role of pharmacies and developed phone lines such as NHS Direct, but GPs still remained the most used with 300 million GP consultations. GPs remain the most-accessed part of the English healthcare system.

31. GPs are comparatively used less for health promotion than their equivalents in other European countries. The Inquiry may want to consider what assists the GPs in other countries to make a bigger impact and is it transferable to the UK.

32. Many GPs say they lack the skills to deliver effective health promotion. Surveys show GPs were prepared to counsel about alcohol consumption but only 21% thought they were effective.

33. Smoking Cessation programmes requires the GP enquiring about patients smoking status & recording it. The QOF system provides prompts and reminders, however it does not incentivise asking those with no current health problems. In other words it is not population based, but targeted at those with health problems. Less than half of GPs consistently advise patients to stop smoking and advice to quit is only given in 20-30% of UK primary care consultations with smokers. 42% of GPs thought discussing it was too time consuming. 22% said they lacked confidence. Is this about emotions rather than facts? It is most likely to be done when a patient presents with a smoking related problem, but less so in other cases.

34. GPs need more support and training to be more proactive. Consideration needs to be given as to how can they be encouraged to take it up. Could local authorities as part of their new public health role have a role through social norms to improve their training?

35. GPs say they are more comfortable managing illness than promoting health despite the opportunities to be proactive. Does there need to be proper research into the varying attitudes and values of GPs in order to achieve behaviour change with them?

36. There is a tradition of individual “activist” doctors addressing public health and ill-health prevention in deprived communities. What are the differences between them and other GPs? Has there been any research into this?

June 2011

Prepared 28th November 2011