Prior to joining the Nuffield Trust, I worked as a public health intelligence analyst in local government. The recent QualityWatch report on public health and prevention struck a chord with my experiences and discussions I have had with others in the field. Whilst the way in which data is collected, shared and used within the new public health system emerged from the report as an issue among senior public health professionals, the public health intelligence (PHI) capability - to translate these data into evidence-based public health planning - is just as important.
Assessing need in the local population
Since the transfer of public Health responsibilities out of the NHS and into Local Authorities (LAs) in 2013, every LA and CCG has had a joint statutory responsibility to assess the current and future health and social care needs of the local population. In oral evidence given to the House of Commons Public health post-2013 – structures, organisation, funding and delivery inquiry, the word “data” came up no less than 93 times, highlighting the pivotal role data play in this process.
There is an array of publicly available data sources from which to draw aggregate data on the local population: The Health and Social Care Information Centre, Office for National Statistics and Public Health England (PHE), to name but a few. The Public Health Outcomes Framework (PHOF) benchmarking tool is often the first stop, allowing LAs to quickly assess how they compare to local and national peers and identify priority areas for improvement. It also encourages a consistency in the indicators that are reviewed across the country and is an enormous timesaver, particularly for stretched PHI teams that sometimes consist of only one staff member.
Patient-level data also provide important information on service utilisation; however, public health teams lost access to these data following the move out of the PCTs. Some public health departments have created local workarounds by negotiating access through the local CCG; others have not. Successful collaboration between public health and CCGs is mutually beneficial: the CCG provides information on the current realities in service provision, while public health maintains a population focus. However, the strength of these working relationships varies widely across the country. In order to provide more national consistency, PHE negotiated HES access for LAs for a period of one year, with the potential for renewal based on uptake. However, concerns around information governance, and appropriate skills to access and analyse these data, have impeded many authorities’ access.
Value of specialist knowledge and intelligence
Public Health funding is ring-fenced within LA budgets at present, but not insulated from spending cuts or wider local authority restructuring. In particular, there seems to be a shift towards moving the PHI function out of public health and into more general corporate intelligence teams.
This creates a risk that PHI may become divorced from the core public health team and in turn, the local CCG. Arguably, this could allow further interaction with the wider determinants of health. However, there is concern that if management comes from the corporate team, this may lead to inflexibility in responding to ad-hoc data requests from the public health team and a loss of strategic PHI direction. This would be a huge step backwards, after years of progress in evidence-based planning.
The move highlights a lack of recognition of the specialist knowledge of the some 1,070 to 1,370 people who work in knowledge and intelligence roles in local authorities and PHE. For analysts, there is certainly a generic level of quantitative skill required, but beyond this, knowledge of epidemiology, the national and local policy context, and a nuanced understanding of the breadth of health and social data is required in order to be able to provide specialist advice and guidance. Only then is it possible to turn the vast amounts of available data into useful intelligence that can be meaningfully translated into action. Public health intelligence identifies where inequalities exist and which interventions can have the most beneficial impact on the population – all the more important in times of austerity. Interrogation of patient-level data is a further layer of technical capability, but the uncertainty around data access, and the timeframe of permissions, makes it difficult to make a business case for further investment in the required skills. A general feeling of uncertainty hangs over the profession.
At a conference last summer, Sir Michael Marmot said “We need evidence. We need hard, solid evidence of what’s going on and what will make a difference, and then we need the passion to make a difference”. I do not believe that anyone would question public health professionals’ passion to make a difference, but my concern is that we may soon be in danger of lacking the evidence.