āTomorrowās a DH funding meeting, George. You are expected to present your business case for the āBioā programmeā, read the new email that had just landed in Georgeās inbox. This was from his secretary, Elaine, who always preferred to send a āgentleā reminder to her boss what she thought needed Georgeās careful attention and probably some focused time preparing for.
Elaine had been Georgeās secretary for the last five years and he was used to her gentle reminders. However, on this occasion, the āgentleā reminder did not sound āgentleā in any way as despite Elaineās and other colleaguesā best efforts, he had not been able to collect the sort of information he was after for the next dayās meeting. Besides, he was just coming back from chairing a local strategy meeting, had another meeting scheduled for late afternoon and, above all, he and his team had been very busy for the last few months working out efficiency savings that they needed to deliver next year. Thanks to the current austere climate, his job had never been this hard!
āThis meeting might turn out to be fiercely competitive, who knows?ā thought George looking at the meeting agenda and the list of attendees, āwithout robust data, and more importantly, without showing economic returns in the short to medium terms, our plan is unlikely to get fundedā.
George always liked his role as the Director of Public Health for the New Maryland local authority (LA). New Maryland is characterised by its beautiful woods, several small but stunning lakes and lovely residents. The population health status was better than the national average, thanks to the abundance of small and medium enterprises (SMEs) that served as the backbone of the local economy.
One public health problem that George and his team were trying to address, however, was the extremely low breastfeeding rates in their local authority, much worse than the national average. Less than 0.1% of new mothers were breastfeeding at four months despite about 60% of all postpartum women in the local authority initiating breastfeeding post birth. The breastfeeding cessation curve for the borough looked odd: most mothers who initiated breastfeeding would turn to breastfeeding substitutes by the 6th week, and by the 12th week, less than 0.1% would be exclusively breastfeeding their babies.
George and colleagues wanted to do something meaningful to improve this situation. They realised that because of the strong local economy in the borough, most women were working in the SMEs. They loved their job and the income it provided. The borough has almost 90% home ownership and most working women hold full-time jobs. Thus, women were more likely to return to work immediately after six weeks of maternity leave. At that point, breastfeeding ceased and breast milk substitutes kicked in.
Having understood the root of the problem, George and his team consulted with women about how the local authority could help continue breastfeeding their babies for (at least) four months or longer. The consultation pointed to a couple of possible interventions George and his team could offer to women: a nursery/childcare closer to the workplace where they can visit their babies and breastfeed and a workplace facility where the working women were able to express breast milk during working hours and safely store it. Having further consulted with the employers and after scrutiny of relevant literature around the possible health gains of continued breastfeeding, George and his team had come up with a plausible intervention, the āBioā. The acronym āBioā stood for āBreastfeeding in Officesā, and it was on Georgeās list of new programmes that needed funding to start this year.
āWe have worked so hard and worked together with women and employers to develop this interventionā, George got nostalgic for a while but soon recovered, āit would be a shame if we were not able to build an economic case for it. I have just a few hours nowā¦ā.
George gave a second thought on what had been a problem in relation to the economic case. āThe evidence on the health benefits of exclusive breastfeeding for four months or longer is pretty strongā, he consoled himself. āBut the evidence on the cost-effectiveness of interventions is rather sparse and where those evidence exist it is hard for us to translate that to our own contextsā, he seemed to be in two minds. āItās the āformatā in which the information appears that seems to be problematic hereā, he concluded.
Soon, his fingers were on the telephone. āPaul, would you like to pop in to my office, please? We need to discuss āBioāā. On such anxious occasions, it was not uncommon for George to count on Paul, his public health analyst.
āYou know George, I found a very interesting new report this morning when you were in the local strategy meetingā, announced Paul after taking a seat at the round meeting table in Georgeās office. āThey talk about the scale of cost savings to the NHS ā¦ if breastfeeding rates in the UK were to increaseā he said as he passed the report on to George.
āI think it does the trick for usā, declared Paul. āOur new intervention āBioā would increase breast milk feeding and given this new evidence, we could calculate how much cost savings it would generate under different assumptions of breastfeeding rates. If we then compared the cost savings with the extra costs to us of implementing āBioā, we would be able to present our business case, wouldnāt we?ā
Paulās suggestion based on this new evidence punched George. āEureka!ā he exclaimed as he struggled to push himself back in to his chair.
The next hour was perhaps the most productive time they spent together working out the business case for the āBioā. Once they realised that the evidence was in the format they needed, it was not hard for them to estimate likely returns from the investment they would require to run the āBioā under different assumptions across New Maryland.
When Elaine came to remind George of his next meeting in 15 minutes, George seemed very confident that he would be able to present a strong business case for āBioā the next day.
āThis meeting might turn out to be fiercely competitive but I may get the funding, who knows?ā he said smiling at Elaine as he left his office.
Elaine knew her boss had got all the information in the format that he needed them.
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Why is Georgeās story relevant here?
Evidence-based approaches to decision making have been on the forefront of public policy for a long time. What works, in what population and with what consequences are the three questions underlying the quest for evidence prior to or during the decision-making process. In the medical sector, the dominance of evidence-based medicine (EBM) as a supplement to traditional medical practice is well known. Clinical (micro-level) decision making is often heavily based on EBM approaches whilst reimbursement (macro-level) decision making involves EBM as just one component. EBM can be defined as āthe conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patientsā [1]. This definition lends itself to a simple interpretationāin order to make evidence-based medical decisions, one has to rely on better (than what is used traditionally), high-quality research information that can be integrated into or with oneās clinical experience and patient values. Judgement is inevitable in such decisions but that is expected to have been informed by reasonable use of ābest evidenceā. Any evidence-based decision would then bring about the maximal benefit to a patient.
The principles of EBM have extended to public health policymaking too. However, there is one fundamental distinction between the two. Unlike in the world of medicine, the aim of public health is to move the interventional benefits from one patient to a large number of people (the population). Unlike a clinicianās focus on improving health of a patient, public health professionals work towards achieving better health outcomes at the population level. How would best available evidence such as the effect size of an intervention coming out from an adequately powered randomised control trial (RCT) translate to public health decision making then?
A slight adaptation is needed to apply EBM approaches to public health. Moving away from individuals to populations, from diagnosis to prevention, from treatment to health promotion and from whole patient to whole community is necessary [2]. Medical care is thus no more the only policy goal; it extends beyond that to include interventions that could mitigate the underlying causes of the low levels of population health such as poor sanitation, environmental pollution, certain lifestyles and behaviours. Is the sort of research information that is needed for evidence-based public health essentially different from the ones needed to practice EBM? The following view articulated by Cairney and Oliver [3] may help answer this question:
Evidence-based policymaking is not just about the need for policymakers to understand how evidence is produced and should be used. It is also about the need for academics to reflect on the assumptions they make about the best ways to gather evidence and put the results into practice, in a political environment where other people may not share, or even know about, their understanding of the world; and the difference between the identification of evidence on the success of an intervention, in one place and one point in time (or several such instances), and the political choice to roll it out, based on the assumption that national governments are best placed to spread that success throughout the country. [3]
Understanding what research information is helpful to make public health policymaking is therefore crucial. As the EBM principles suggest, the evidence should be robust, usually coming from more than a single study (e.g. from systematic reviews, meta-analyses and economic evaluations) and presented in a critical way to guide users to choose what is known as the ābest available evidenceā. The Cochrane initiative uses stringent criteria to āgather and summarize the best evidence from researchā [4] to aid the decision-making process. The evolution over time of national guideline development bodies, such as the National Institute for Health and Care Excellence (NICE) in England, has clarified the attributes of best available evidence [5]. The Health Technology Assessment (HTA) programme that aims to combine clinical effectiveness/health outcomes information with costs provides a framework upon which evidence needs to be developed, scrutinised and presented [6].
Increasingly, cost-effectiveness evidence , most of which is presented in the form of incremental cost per QALY (quality adjusted life year) gainedāto reflect the additional cost of generating one extra year of full health at the population levelāis being used to make treatment choices in the NHS and beyond, including public health interventions. NICE considers an intervention would provide good value for money if the cost per QALY is preferably under Ā£20,000 but not above Ā£30,000. Health economists argue that presenting research information as explicitly as incremental cost per QALY is useful for decision makers because it helps them consider whether the benefits of a new treatment are worth the health displaced elsewhere by their decision to fund that treatment.
If this was that straightforward, what would explain the struggle for obtaining the right information in Georgeās story?
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That question has haunted us for the last seven years!
In 2010, we started to look at the economic impact...