David Hunter
Emeritus Professor of Health Policy and Management
Newcastle University, United Kingdom
Newcastle University, United Kingdom

The Prioritisation Framework for public health investments – Public Health England

The Prioritisation Framework is an excellent example of investing and disinvesting to make improve the use of existing resources. To learn more about this method, visit investing & disinvesting.

 

The Prioritisation Framework (PF) provides a platform to aid local authorities to make decisions regarding budget allocations in a structured and transparent manner.  The notion that public health resources are scarce is not new. Within the constraints of a fixed budget, a decision to provide one service may result in another service not being provided due to lack of resources.  Thus, being aware of the resources used and benefits of various services or interventions for public health allows comparisons and choices to be made to invest in a combination of services  that maximises the benefit from the fixed budget.

One method of facilitating the application of health economics principles to public health priority setting is through the use of multi-criteria decision analysis (MCDA). This is a domain of operational research that is starting to be used in healthcare decision-making. The technique recognises that decision-makers employ multiple and disparate criteria when making decisions (e.g. introducing new health care interventions or facilities), and that it is important to make explicit the impact on all criteria applied and the relative importance attached to them. In MCDA, criteria affecting a decision are identified and weighted using explicit, transparent techniques. Different options (strategies, interventions) are scored against each weighted criterion to provide summary scores for comparative purposes. It helps to make assumptions that underpin decisions more transparent, which may improve accountability and consistency of decision-making.

The PF was based on MCDA largely because it has been used effectively to support strategic decision making in many different public health circumstances and contexts, such as multi agency working. The PF allows for consideration regarding programmes that can offer best value, the current states of programmes, budgets and how they are currently allocated across programmes, and how easy it could be for the programmes to change and improve. The process allows public health programmes to be scored on the potential state, current state and the programme budgets while, at the same time, considering what is achievable. The purpose of this is to be able to make informed recommendations on whether to increase, decrease or maintain budget spending in each public health programme.

How best to achieve better investment and disinvestment decisions has long been a challenge facing policy-makers. However, following deep cuts to public spending in England since 2010, the issue has become more urgent and acute. In 2012, a group of UK researchers, some initially based at Durham University, and then at Newcastle and Northumbria Universities together with colleagues from the Universities of Sheffield and Kent, undertook a number of linked studies exploring the application of priority-setting tools that local authority public health decision-makers might find useful for investment and disinvestment decisions. Funding for the research came from the National Institute for Health Research (NIHR) School for Public Health Research (SPHR) and full details of the programme of research conducted from 2012-2016 and its findings can be found here and also under Current Research Projects.

Exploring methods for supporting public health commissioners in priority-setting to improve population health and address health inequalities project informed a new Prioritisation Framework developed by Public Health England (PHE) and launched in March 2018.

The PF comprises eight essential steps that can potentially take place over a number of workshops. Those taking part in the workshops would ideally be stakeholders from each of the health programmes under consideration.

Step 1 defines the criteria against which programmes will be evaluated. Operational criteria are selected during this stage of the process, representing key factors of what is to be achieved within each local authority and weights are then applied to each of the criteria in Step 2. The weights that are assigned to each represent the importance of each criteria relative to all others with the total score summing to 100.

Step 3 involves gathering evidence from each programme area that is relevant to the criteria. The evidence gathered relates to what could potentially be achieved by each programme area against each criterion.

Step 4, after collecting evidence, rates each of the programmes from 1 to 5, with a score of 1 representing the poorest and 5 the best. The higher the score indicates which programme areas have the best potential to achieve positive outcomes.

During Step 5 the weights that were assigned to the criteria and the scores given to the programme areas are combined to calculate an overall score. This final score represents the overall outcome of what could potentially be achieved by each of the programme areas.

Step 6 is used to gather evidence regarding the current expenditure and outcomes of the programme areas. Step 7 assigns scores, with the scoring based on the evidence of the current achievement of the programmes against 3 measures: investment, outcomes, and feasibility. Each programme is given a score from 1 to 5 against each of these measures. Overall, the score gives a clear representation of how the programmes are currently doing in a numerical form.

Finally, in Step 8, the PF produces recommendations on whether to maintain, increase or decrease the current budget allocations. The stakeholders then have the option of following what has been advised or to decide their own actions in the light of other contextual factors.

Given the short-term nature of the study it did not prove possible to say much about the impact of the PF on priorities and on investment and disinvestment decisions or to conclude anything in regard to the extent to which it affected spending decisions.  However, it is important to stress that the PF is not primarily a health economics tool and is not seen as such by PHE. The primary value of the PF lies in providing structure and guidance for local decision-makers to agree the outcomes they regard as important.  Consideration of the evidence in regard to effectiveness and cost-effectiveness is only one part of the overall decision-making process.

While the act of assigning numerical scores to the evidence is important, it is only a means to an end and should not be over-emphasised.  More important than the scores are the conversations triggered by employing the PF, which allows decision-makers to express their views, challenge assumptions, and agree on the best course of action.

PHE has accepted the main study findings and plans to incorporate these where possible in future versions of the PF and efforts to roll out the tool across all local authorities in England. Members of the team who developed the PF published a blog in response to  the final evaluation report.

For more information on the Prioritisation Framework, click here.