KHP Research Grand Challenges. The KHP vision for Delivering Excellence in Urban Public Health Executive Summary (March 2012)

Transcription

1 KHP Research Grand Challenges The KHP vision for Delivering Excellence in Urban Public Health Executive Summary (March 2012) Over the next five years we aim to be recognised internationally for our academic excellence and service innovation and implementation in Public Health (PH) with a specific emphasis on Urban Public Health. We will address local issues with international applicability, with a focus on inequalities, particularly with regard to ethnicity and deprivation. We will explore cost effectiveness of healthcare delivery, encompassing both physical health and mental health and wellbeing. We will work with key partners (including KHP s Clinical Academic Groups, local communities and stakeholder groups, PH & commissioning groups and healthcare providers in primary and secondary care across the South London sector, together with national and international partners) to create a receptive environment to develop and deliver innovative solutions to improving public health. This will focus on prevention and management of long term conditions of public health importance within our multi-ethnic, urban populations. We will work closely with local communities in designing and implementing such interventions, which will comprise a basket of risk reduction approaches, as well as improvements in the efficient delivery of health and social services. Our initial programmes will address inequalities through pilot work in agreed local priorities (childhood obesity, alcohol, and the frail elderly) which will support the development of generic methodologies and capabilities that are applicable to all aspects of PH. These pilot programmes will require pump-priming investment (e.g. from the GST Charity and KHP partners) to create the academic capacity needed for delivery. In parallel, we will strengthen our educational programmes to make these both attractive to (inter)national students, and also develop appropriate educational programmes in PH for local managers and practitioners, building a broader awareness and understanding of PH perspectives, methodologies and potential for interventions across our local communities and networks of collaborators and providers. We propose that this local work be co-ordinated and driven by a newly established KHP Institute of Urban Public Health. The Institute will be crucial to our achievement of an international profile for both academic and service delivery excellence in Public Health, and will be a focus for the development of (inter)national collaborations and partnerships. The Institute will have core Public Health Faculty members, and will encourage Associate Faculty membership from a broad range of academics and practitioners involved in the research and training initiatives. It is proposed that the Institute be housed in dedicated accommodation at Guys with space to encourage interdisciplinary working to address the PH issues. 1

2 1. Background and Context The Government s Strategy for public health (Healthy Lives, Healthy People, 2010) emphasised the need for a radical shift in the way we tackle public health challenges. We have to be bold because so many of the lifestyle-driven health problems we see today are already at alarming levels. The Government has stated that this is a new era for public health, with a higher priority and dedicated resources and commitment to protecting the population from serious health threats; helping people live longer, healthier and more fulfilling lives; and improving the health of the poorest, fastest. Shifting the focus of the national health and social care service away from treating ill health to an emphasis on prevention and improving health and has been a major priority for successive governments. It is seen to be a major factor in controlling the growing burden of ill health and containing the escalating costs of healthcare, in the context of an ageing population with increasingly unhealthy lifestyles. However, designing and implementing evidence based initiatives which are effective at improving public health is extremely challenging and complex, requiring expertise in many different disciplines and the engagement of multiple professional groups and organisations. Definition of public health The UK Faculty of Public Health defines public health as: The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society. The Faculty's approach is that public health: is population based emphasises collective responsibility for health, its protection and disease prevention recognises the key role of the state, linked to a concern for the underlying socio-economic and wider determinants of health, as well as disease emphasises partnerships with all those who contribute to the health of the population. Three key domains of public health practice: 1. Health Improvement (e.g inequalities, lifestyle, employment) 2. Improving services (e.g. planning, clinical effectiveness) 3. Health Protection (e.g. infectious diseases, emergency response) Delivering this mission requires the generation and use of new research data derived from evidence of not only the effectiveness of interventions but also their comparative value ( cost-effectiveness). 2

3 The KHP Grand Challenge Group recognises the wider determinants of health. The necessary skills to address many elements relating to the determinants of health and societal perspectives, as well as developing methods that are relevant to the broad public health agenda are available in our multidisciplinary Faculty. However, our distinctiveness and future strength should be focussed on developing, evaluating and scaling up public health interventions that reduce risk and promote health and well being. Thus, our focus is principally on 1) health improvement, as well as 2) improving services. KHP strategic framework and priorities Prior to receiving formal accreditation as an Academic Health Sciences Centre, the organisations which together form King s Health Partners were united in a core mission to improve health and health outcomes for the patients and populations which we serve, and to tackle local inequalities in health. Measures such as mortality, years of life lost, pregnancy rates, prevalence of addictions and crime within local boroughs, all starkly highlight the extent of these health inequalities. This focus on improving the health of the local populations was endorsed in the Strategic Framework document, published 6 months after receiving formal accreditation. This states that KHP wishes to work with others to: Improve the health and wellbeing, including mental wellbeing, across our ethnically and socially diverse communities and working to reduce inequalities Transform the nature of healthcare: by moving from treatment towards population screening and disease prevention Be inclusive: by designing systems and procedures so that everyone is actively encouraged to become involved and has the opportunity to do so Hence, public health is recognised as central to KHP s mission, and our relationship with the large and diverse population that we serve is a unique feature of our AHSC. The emerging local public health strategy In recognition of the importance of public health to KHP, Charles Wolfe, supported by Zoe Reed, was asked to lead on the creation of an overarching public health Strategy, developed in close collaboration with the multiple public health leaders and partners who have a role in improving public health locally. Five key interdependent themes have been identified for the KHP public health agenda which are: 1. Developing academic capacity to design interventions and contribute to delivery of the strategy 2. Developing the culture of Clinical Academic Groups so that they are public health focused in all their behaviours and priorities 3

4 3. Delivering public health interventions to reduce risk and improve health and wellbeing 4. Community Involvement to improve public health 5. Public health Collaborative for joint working to identify priorities and maximise the offer and availability of expertise and information to secure change for improvement. This strategy addresses the first of these themes. Academic capacity and capability is a critical element of the overarching KHP public health strategy, as it is the area for which KHP will provide the leadership in the local public health arena. The focus on improving local public health is strongly supported by the Guy s and St. Thomas Charity, which has earmarked substantial funds to support collaborative ventures which address local public health challenges. It is recognised that this Grand Challenge will need to be integrated with research strategies for Primary Care, as well as strategies for stakeholder engagement / Public Patient Involvement. Primary Care Research Strategy KCL has a joint academic department of Primary Care and Public Health Sciences reflecting the shared methodological underpinnings and the requirement for a joint approach to meeting public health challenges. Primary Care focuses on three specific areas: Primary care epidemiology: Large dataset epidemiology based on local care data (Lambeth Datanet and QOF). Pharmaco and genetic epidemiology, with links to the two BRCs at KHP and translation. Clinical studies: Chronic Obstructive Airways Disease health services research, large collaborative studies involving the Primary Care Research Network Decision Making and Informatics: Decreasing diagnostic error, clinical research informatics and decision support for diagnosis. The Grand Challenges In 2010 when the new Director of Research for KHP was appointed, he identified 4 Grand Challenges which KHP will need to overcome if it is to excel in research. These challenges are not unique to KHP, and can be related to all aspects of research activity, from basic science through clinical research to health services research and evaluation. However, across KHP we have a number of distinctive strengths which make us ideally placed to respond to these grand challenges, if we harness our potential effectively. The four grand challenges are: (1) discovery, development, experimental medicine and clinical trials (2) research informatics (3) public health research (4) personalised medicine 4

5 In addition, a further work-stream is exploring how we may engage all staff groups across KHP in participating in, and / or supporting research activity. The grand challenge process therefore created a structure by which the first theme of the overarching KHP public health strategy (developing academic capacity) could be taken forward. Work of the Public Health Research Grand Challenge Group Using a similar approach to the other grand challenge groups, the public health research group was established to bring together those with interest and expertise in this field, from across KHP as well as local public health input (Appendix 1 membership of GC PH Group). The group set out to: Agree our ambition for academic public health at KHP Map the of breadth of skills and expertise currently existing Identify the skills and capacity required to deliver our ambition (initially to lead and manage 1-2 complex programmes in priority areas) International fact-finding exercise to learn from prominent Schools of Public Health Consider models for appropriate organisation and leadership in academic Public Health for KHP Reach initial agreement on our niche and focus 2. Current KHP Capabilities in Academic Public Health Academic expertise in core public health is focused within the Division of Health and Social Care, which sits in the KCL School of Medicine. In addition, Public Health research draws on a wide range of associated disciplines and expertise across KHP and beyond. In response to a call from NIHR to establish Schools of public health within the UK, an internal mapping exercise was carried out, which identified key researchers in public health (application attached as Appendix 2). This demonstrated that although KHP does have capability in PH (with a total of 33 key researchers with some expertise in the broader field of public health identified) we have only 2 senior core Public Health specialists. The NIHR panel considered the strategy for public heath to be strong, but the ability to undertake public health interventions was limited, given out core capacity in this area. They also noted our significant strengths in primary care and mental health as being relevant, but considered these not core to the notion of a national School of Public Health. 5

6 3. The Strategy for Public Health Research We aim to improve public health and well-being, recognising that there is no health without mental health, through our translational research pipeline with interventions in communities and populations at the core, supported by innovative methodological developments. Through KHP, and its Institute of Urban Public Health and enabling networks, we have the potential to drill down to local communities to: (a) identify problems (b) understand their determinants (c) develop and test interventions and (d) implement these Interventions: The programmes of work will be delivered by the communities, stakeholders and key researchers, under the direction of the Institute s academic leadership team.. The areas of focus for the interventions we develop (Late Translation) (see Figure below) will address inequalities and draw on our current strengths and address key areas of risk reduction (primary and secondary prevention) - particularly in lifestyle risk, Public Mental Health, quality of health and social care for long term conditions. Platform for the intervention: Areas of development will include methods to standardise data collection across health and social care to assess risk and improvement in health and wellbeing; informatics to inform the new epidemiological sampling frames that will be required; statistical and health economics methods to evaluate interventions and model their cost effectiveness; social science methodologies to develop and evaluate complex interventions; implementation sciences and management methods to ensure uptake of effective innovations in public health workforce development and interventions in health improvement. Stakeholder and public engagement. We will draw on our local experience in stakeholder involvement in public health, using organisations such as London Citizens, Timebank and local patient User groups. The aim will be to increase social cohesion through increased opportunities for engagement. The focus will be on these groups developing, piloting and assisting in delivery of the interventions, which will mean working with local government, the Mayor s office, and relevant health and social care agencies. 6

7 This strategy is set out in Figure 1 below : The Intervention, Development and Evaluation (IDE) pathway and key competencies The group initially mapped competencies and potential ways to develop complex Public health Interventions (Appendix 3 for details) Building on the MRC s (2008) framework for the development and evaluation of complex interventions, public health and primary care intervention development and evaluation can be conceived as a pathway with a number of stages outlined in Apendix 2 It should be noted that the realities of public health and primary care practice mean that activity on intervention development and evaluation may not always occur in an orderly linear manner Instead, there are a number of potential points/cues where KHP may become involved in the IDE pathway. These points are alsoillustrated in Appendix 3 Finally, Figure 2 summarises the complexity of developing such interventions and illustrates the range of capabilities required. Figure 2 7

8 Public Health Translation Pull Through METHODS: Public Health Statistics Social Science Economics Psychology EVALUATION: Single & Complex Realistic Pilot Stakeholders SCALE UP? IMPROVEMENT SCIENCE Delivering the Strategy In order to deliver the strategy we will need to : (a) build capacity in key disciplines (internally and through collaboration) (b) focus on one or two priority areas in inequalities (e.g. childhood obesity and alcohol) in order to launch major work programmes If we develop 1-2 large scale, complex interventional studies, linked to the specific local health needs of our populations (i.e. (b) above), we can begin to demonstrate the value of a rigorous academic approach to improving local urban public health. This work can be further developed to create the concept of a living laboratory in our local boroughs. Over the longer term we would be seeking research grants from major funders to sustain a significant research programme in public health. In the short term, we may require pump priming funding in order to establish research activity and produce preliminary findings to present to research funding bodies. 4. Organisation and Leadership of Academic PH Learning from International Schools of Public Health A series of video conferences were organised between the Grand Challenge Group and a number of the most prestigious Schools of Public Health internationally (Harvard, Johns Hopkins, University of North Carolina, Toronto, Sorbonne). 8

9 A wide range of topics was discussed, summarised below : Organisational form It takes considerable time and resource to establish a successful School of Public Health (i.e. in many cases several decades). It is therefore important to be clear about the benefits and value as well the costs, and to have passionate individuals prepared to drive forward. The appropriate structural model for KHP will be specific to our local context. In order to have a high quality Public Health School, it is important to attract the best people in associated disciplines who will contribute to teaching and research programmes. However, these individuals will usually wish to retain their home in their primary discipline, rather than be working at a smaller critical mass in a multidisciplinary environment with a number of other professional / disciplinary groups. A potential solution to this tension is to create a virtual school, or a matrix organisation, which provides dual affiliation. A number of Schools had the concept of adjunct or associate faculty members who contributed to academic programmes within the School of Public Health, or in some cases joint appointments. These arrangements can help to cement collaborations. These appointments could be from KHP s local partnerships, but also from national and international institutions. Appropriate incentives may also be required in order to gain commitment from those with the necessary expertise. Focus of the School There were significant differences in the extent of focus on research vs teaching. Public universities heavily focused on education and teaching (underlined by the accreditation process) and in some areas were monopoly providers for training practitioners (and managers). The private universities prioritised research, which was their major source of income. However, the private universities acknowledged their strategies were now giving more attention to the education agenda. There were also marked differences in staff : student ratios (from 1:15 to 1:3). All Schools acknowledged the tension between having an international research reputation and working with the local community to impact on local public health issues. Whilst it was considered possible, with diverse and multicultural city populations, to have global applicability (and methodology should be generalisable) none of the Schools felt they had achieved the balance and therefore this was an underdeveloped area. Mental health and primary care - none of the schools stood out as leading in this area, and most admitted minimal focus and the need for more explicit recognition. A Proposed Model for KHP Public Health It is proposed that we develop a distinctive niche in the area of Urban Public Health. This will allow us to develop strong relationships with our local communities (working as a local test bed for demonstrating improvements in public health) as well as highlight global applicability through new relationships with international partners. 9

10 Based on strong messages received from the international Schools we are proposing that we begin by establishing an effective matrix structure in the form of a KHP Institute of Urban Public Health. This could be rapidly launched, and would give focus for : 1. capacity building & new recruitment 2. effective engagement of the local PH community 3. new work programmes in 1-2 priority areas A leadership team (including academic leadership and implementation leadership i.e. for PH delivery, as well as senior management support) should be established, working with a core grouping of public health professionals. In addition, a wide-ranging Faculty would be established with Associate Members who may be contributing to educational and research programmes, as well as practitioners who would wish to maintain professional links with the Institute via engaging in seminars, accessing website, etc. A physical Hub will need to be identified, providing space for developing interdisciplinary working around Core activity. This could potentially be created following the move of the current Division of Health and Social Care later in the year. It is envisaged that members of the Faculty would also have the opportunity to interact in a number of different ways, for example via Seminar programmes, a website / interactive forum and regular newsletters, etc. Primary Care should continue to grow alongside Public Health in Institute. We will shortly be advertising for a replacement Wolfson Chair with supporting fixed term Clinical Senior Lecturer and non-clinical lecturer. Strategically this should be aligned with a major clinical research area such as diabetes, cardiovascular disease in order to continue to support capacity in the SE London Primary Care Clinical Research Network. Key Relationships The KHP Institute of Urban Public Health will have a number of important interactions across KHP and beyond. These would include the King s Improvement Science Initiative, the NIHR BRCs and research design Service, the Academic Health Sciences Network. KCL has recently signed an MOU with the National Institute of Health and Clinical Excellence (NICE) and NICE International provides the opportunity to build relationships rapidly with relevant overseas partners. In addition, we have relationships with the WHO which could be further developed. 5. Developing Educational Capacity Increasing the capacity for teaching leadership will enhance opportunities to extend training locally (more part-time training attachments, wider range of elective study opportunities) and globally (develop a distance learning course with KCL grad school and NICE International support, that is likely to be very attractive to international applicants). 10

11 Current Educational Programmes Master of Public Health (MPH) The MPH curriculum has a strong emphasis on prevention and the broader determinants of health, and is aimed at graduates or holders of a relevant professional qualification who are working in, or intend to work in, the broad field of public health. We also offer MPH students the opportunity to take certain modules from the MSc in Public Services Policy and Management. The orientation is towards high income countries and most subjects are taught in a UK context, though we take many students from overseas. The MOU with NICE will offer opportunities to collaborate with NICE s Centre for Public Health Excellence in delivering teaching opportunities. MPH (Primary Care) From September 2012, the highly regarded MSc in Primary Health Care will merge with the Master of Public Health programme. The roles undertaken by GPs, and other members of the Primary Care team have continued to develop and the recent White Papers indicate further major changes to the organization and delivery of healthcare. GPs will play a central role, with implications for education and training. MSc in Public Services Management and Policy The Dept of Management runs a successful and distinctive MSc in Public Services Management and Policy on which some modules are already open to MSC PH students. This programme includes an introduction to core generic management subjects taught within a public services context (e.g. Accounting and Finance; HRM; Economics; Leadership) as well as a specific Health Policy option. Future Developments We are considering adding Strategic Management in the Public Services option which will be important in the new style NHS. There is a strong research interest in health care organizations and organisational change in the dept which could be built into a teaching offering. We will also explore the development of new short courses (e.g. developed from Masters modules as stand alone courses) or alternative delivery mechanisms (e.g. blended learning, being developed by the KHP Education Academy) for local clinicians undertaking part time management roles, who may need more focused learning opportunities. In order to deliver expanded educational programmes we will need to expand the number of individuals contributing to teaching and supervision, for example through wider Associate Faculty membership, and through drawing in specific expertise based on our developing partnerships and collaborations. 11

12 6. Engaging Local Practitioners and Public Health Leaders There is a solid foundation of collaborative work with local boroughs that can be built upon. The concept of an Institute may provide a more formal framework for engagement, for example, local LAs may wish to become Associate Members of the Institute, if through this relationship they obtain assistance with local PH initiatives and a network of professional support. A further important mechanism for local engagement will be via KHP s Clinical Academic Groups (CAGs). All CAGs have been asked to consider their role in local PH improvements, and how they interact with primary care and other relevant colleagues locally in order to achieve this. Provision of education to a broad community of health practitioners and managers will also serve to strengthen local relationships and networks. 7. Links with other KHP work programmes The vision and capacity building outlined by the PH Grand Challenge group will contribute to the other Grand Challenges, and there has been significant cross representation. The GST/KCL BRC s Population Sciences Cluster provides interdisciplinary skills in public health, primary care, environmental Health, epidemiology, statistics, health economics and social sciences for research and training, along with Theme programmes in Environmental Health, Cancer, Transplantation and Stroke that will contribute to optimising the focus, effectiveness and impact of translational research in the BRC. We will study how best to pull through early discoveries to the local ethnically and socially diverse communities to reduce inequalities and transform the nature of healthcare by moving to disease prevention, population screening and stratified medicine in primary care. We will aim to integrate more effectively with the other Clusters and Theme projects in an interdisciplinary fashion by: engaging communities in research; informing the translational agenda of health care needs (epidemiology) and priorities for preventive and therapeutic interventions; model the potential population impacts (outcomes and cost effectiveness) and investigate the effectiveness of different models of translation. The major questions for the BRC are: 1. Promoting excellence and effectiveness in translational research: (i) How can the BRC engage and access populations effectively? (ii) How can the translational research pipeline be made more effective and efficient to improve clinical and population outcomes? 2. How can a digital infrastructure support a learning healthcare system? 3. Does personalised medicine improve population health? 4. What is the effect of the environment on respiratory and cardiovascular health? 12

13 The key BRC delivery groupings required to address these questions are: - Populations, patients and pull through sciences - Informatics platform - Datasets for epidemiology - Environmental health - Consultancy services/interdisciplinary working with BRC Clusters Biomedical Research Public Health Pull Through Epidemiology Needs Outcomes Trial Design Power Outcomes Predictive Models Sociology Evaluation 13

14 9. Summary of Recommendations and Next Steps Recommendation 1. Build academic capacity in public health 2. Agree appropriate leadership and governance arrangements for academic public health 2. Launch 1-2 major research studies with complex public health interventions in key priority areas for local population (e.g. alcohol and childhood obesity) 4. Build education and training capacity 5. Develop collaborations and partnerships Proposed Actions Develop a detailed plan for recruitment to key academic posts - in core public health as well as associated disciplines (e.g. behaviour change, and health economics) Begin search process for senior academic posts Explore potential for joint posts through our PH collaborations (e.g. health economics with LSE) Consider models / resource for senior managerial support Bid to GST Charity to support capacity building Agree details of the operation of the KHP Institute of Urban Public Health (including leadership team, mechanisms for associate membership, physical location / hub, etc) Plan formal launch of the Institute Determine Faculty Membership from across KHP, national and international partners and identify potential Associate Members Create Institute identity through seminar programmes, newsletter, website, etc. Finalise with local PH & community leaders areas of focus for pilot studies (e.g. child obesity, alcohol, frail elderly) Source pump-priming to design, deliver and evaluate large, complex studies in pilot areas, with multiple evidence based interventions Focus on methodological development, with wide applicability to PH issues grant applications to be developed as pilots begin to deliver results Expand current Masters programme, linking with the Dept of Management Adapt modules for wider educational programmes, e.g. for local managers and practitioners in basic public health skills and awareness as well as international modules Follow up links with international schools (from video-conference), with a view to developing joint projects or more lasting collaborations Establish links with other London PH groups Input into development of NICE global plans Revisit relationship with WHO to explore collaborative opportunities 14

15 Appendix 1 Grand Challenge for Public HealthGroup - List of Members Name Charles Wolfe (Chair) Andre Tylee Brendan Delaney Alison Wright Danny Ruta Denise Lievesley Farasat Bokhari Femi Odesanya Graham Thornicroft Janet Peacock John Moxham Martin Gulliford Matthew Hotopf Simon Howell Simon Wesseley Theresa Marteau Zoe Lelliott Zoe Reed Ollie Smith Organisation KCL Public Health Science KCL Health Sciences & Population Research KCL Public Health Science KCL Primary Care & Public Health Sciences Joint Director of Public Health NHS Lewisham & London Borough of Lewisham KCL Social Science & Public Policy KCL Public Health Science GP Clinical Commissioner KCL Health Services and Population Research KCL Health & Social Care Research KHP Director of Clinical Strategy KCL Public Health Science KCL - Psychological Medicine KHP Deputy Director of Research KCL Psychological Medicine KCL Health Psychology KHP - Head of Research Management SLAM Executive Director for Strategy & Business Development GSTT Charity Director of Strategy 15