Moving upstream: SEWAHSP and Public Health

1. Moving upstream:SEWAHSP and Public Health Moving upstream:SEWAHSP and Public Health Laurence Moore DECIPHer Schools of Social Sciences and Medicine Cardiff University

2. Why move upstream? • Action outside NHS to support NHS needs • How to more forward • Local excellence • Future potential

3. Upstream-Downstream

4. Why focus upstream? A: To Improve Public Health Since 1900, the average life expectancy for Americans has increased by about 30 years. Public health initiatives account for about 25 of those additional years. *Turnock, BJ. Public Health: What it is and How it Works, 3rd Edition. Sudbury, MA: Jones and Bartlett Publishers, 2004.

5. Top 10 Public Health Achievements • Increased average lifespan • 1900: 49 years • 1999: 75 years • Sanitation and water • Vaccination • Control of Infectious Disease • Safer Workplaces

6. Top 10 Public Health Achievements • Healthier mothers and babies • Family planning • Safer food • Heart disease and stroke prevention • Smoking Public health improvements = 20 years added to lifespan Medical improvements = 5 years added to lifespan

7. Why focus upstream? B: To Help Sustain NHS Wanless: critical importance of public health in defining the affordability of the NHS Threats to NHS sustainability: • Health inequalities • Obesity • Alcohol • Diabetes • Chronic disease • Mental Health • Cancer All avoidable!

8. Nice in theory “Health promotion doesn’t work” “No evidence base"

9. Nice in theory “Health promotion doesn’t work” “No evidence base"

10. Owen et al (2011) J Public Health “With pressure on budgets and fundamental changes underway in the NHS and public health structure, there is a need for evidence to support the case for investing in public health interventions. This is the first study to provide a comprehensive list of the cost-effectiveness of public health interventions. Using a standard set of methods, the analysis has shown that the vast majority of public health interventions considered thus far by NICE are highly cost-effective.”

11. Cost-effective solutions often lie outside the NHS • As with infectious disease….. • …environmental health…. • effective preventative actions lie outside the NHS

13. How to move forward? • Transdisciplinary action research partnerships • Researchers from multiple disciplines working with policy and practice partners on NHS priorities • Behavioural, social, environmental, organisational sciences as well as medical and health sciences • Applied team science focussing on research questions identified by service partners • Multiphase projects, complex interventions • What works, for whom, under what circumstances, why and at what cost?

14. SEWTU “Funded by the National Institute for Social Care and Health Research (NISCHR) in October 2006, the South East Wales Trials Unit draws together existing expertise in trials and other well designed multi-centre studies to form an experienced team to support excellence in Wales.” • Around 55 staff • Psychologists, statisticians, dieticians, midwives, sociologists, IT specialists, qualitative researchers etc • 2011/12 running 62 studies totalling £44,355,865

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16. Knowledge Exchange Cycle Front line Innovation Local focus Ivory towers REF / RAE Agenda Publications

17. Excellent environment to support applied public health / primary care research and translation to improve services • Service-relevant applied research questions to drive agenda and resource allocation • Attract excellent research teams to form around these questions • Requires supportive processes and criteria • DECIPHer/PHIRN RDG model • SEWTU model • Bristol Health Partners HIT model

18. Stemming the tide of antibiotic resistance (STAR). A blended learning programme addressing appropriate antibiotic prescribing in general practice.

20. What the clinicians said? • GPs were concerned about the issue of antimicrobial resistance and agreed it was growing. • Many said they infrequently encountered its consequences in their practice and some questioned the evidence linking their prescribing decisions to resistance and poorer outcomes for their patients. • They felt conflicted by their apparent inability to influence the problem in the face of many other competing demands. • They would welcome more information about resistance patterns locally, and felt that undergraduate and graduate education about antimicrobial prescribing and resistance should be enhanced. • A few mentioned that a heightened awareness of antimicrobial resistance locally may cause them to prescribe more second line agents as empirical therapy

21. What next? • A group of clinicians, psychologists, statisticians, web designers, educationalists, health economists etc got together. • We developed a theory based ‘blended learning’ programme to promote appropriate antibiotic prescribing.

22. Method • The study is a randomized controlled trial with general practices as the unit of randomization and analysis. • Process evaluation. • Cost effectiveness evaluation

23. Study Recruitment and Training • 70 practices recruited across Wales • 68 practices randomised (2 withdrew) • 33 practices each in the Experimental and Control Group • Experimental Group: • 33 seminars completed • 127 GPs/NPs completed online training • 31 process evaluation interviews conducted • Control group: • 117 GPs/NPs participating

24. Results: Cost Effectiveness • The mean cost of the STAR Educational Program was £2,923 per practice (SD = £1,187). • There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared to the control (p = 0.07) equivalent to a reduction of about £830 a year for an average intervention practice.

25. 4 year follow-up data • After controlling for baseline dispensing rate, there was a 6.2% (95% CI=1.7%, 10.6%) reduction in total oral antibiotic dispensing for the 4th year following the intervention in the intervention group compared to the control group (p = 0.009).

26. What can we take from these results? • The STAR programme led to a statistically and clinically important reduction in antibiotic prescribing at one and four years following intervention delivery • Achieved with no evidence of increased complications or reconsultations • A relatively brief intervention of around 5 hours can make an important difference even 48 months down the line • Readily implemented in practice at low cost and cost effective, probably cost saving

27. Study Publications • Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial.Butler CC, Simpson SA, Dunstan F, Rollnick S, Cohen D, Gillespie D, Evans MR, Health SL, Alam MF, Bekkers MJ, Evans J, Moore L, Howe R, Hayes J, Hare M, Hood K, BMJ , Volume 344 (2012) pp.d8173-d8173 • Enhancing the quality of antibiotic prescribing in primary care: qualitative evaluation of a blended learning intervention.Bekkers MJ, Simpson SA, Dunstan F, Hood K, Hare M, Evans J, Butler CC, STAR Study Team None, BMC Fam Pract , Volume 11 (2010) pp.34-34 • Stemming the Tide of Antibiotic Resistance (STAR): a protocol for a trial of a complex intervention addressing the 'why' and 'how' of appropriate antibiotic prescribing in general practice.Simpson SA, Butler CC, Hood K, Cohen D, Dunstan F, Evans MR, Rollnick S, Moore L, Hare M, Bekkers MJ, Evans J, STAR Study Team None, BMC Fam Pract , Volume 10 (2009) pp.20-20

28. A peer-led social network based smoking prevention intervention for adolescents: findings from a randomised trial in UK schools (The ASSIST study)

29. ASSIST intervention • Developed in response to discussions with Health Authority and in partnership with them & WG • Year 8 (aged 12-13) • Not a ‘typical’ school-based peer-led intervention • Influential students nominated by their year group • Trained to be ‘peer supporters’ to diffuse norms of non- smoking behaviour through their social networks • Adapted from Kelly’s (1997) sexual health ‘gay hero’ / Popular Opinion Leader in US mid-west

30. Peer nomination • Did not want only ‘high-achieving’ females • Did want influential students • Did want a mix (sex, friendship group, behaviour) • Identified through three questions: • Who do you respect in Year 8 at your school? • Who are good leaders in sports or other group activities in Year 8 at your school? • Who do you look up to in Year 8 at your school? • Viral marketing through social networks

31. Peer supporter training • Parental consent obtained • Peer supporters given two days of training off school premises • Training delivered by outside trainers • Peer supporters trained to intervene in everyday situations (e.g. at break-time, after school) to encourage other Year 8 students not to smoke

32. What evidence do we have that it is effective?Campbell R et al. Lancet 2008;371:1595–1602

33. Study design Randomised controlled trial: 59 schools (10,730 pupils) Two centres: Bristol and Cardiff Outcome evaluation • self-reported smoking status (questionnaires) • salivary cotinine status (saliva samples) • baseline, post intervention, Year 1 and Year 2 Process evaluation Economic evaluation Social network analysis

34. Results, Conclusions, Impact • ASSIST intervention is effective in reducing adolescent smoking • Findings generalisable to range of schools • If implemented on a UK-wide basis could prevent 40,000 14-15 year olds taking up smoking • Recommended by NICE • Cost effective under highly conservative assumptions • Company set up by Universities to license intervention • Now implemented across Wales and England

35. Future potential • Alignment of LHB, Public Health Wales and Welsh Government priorities • Excellent data linkage to support service evaluation, trials, needs assessment and epidemiology – SE Wales Laboratory • SEWTU and DECIPHer • Excellence in high quality applied translational research in primary care and public health