Impact case study database

Creating a new evidence base for priority setting in the new NHS Long Term Plan

The chief executive (CE) of NHS England (NHSE) met the CE of PHE in 2018 about the developing Long Term Plan (LTP) for the NHS from 2019-24. NHSE needed robust evidence on the burden of different conditions across England, and the PHE chief executive recommended the pre-publication Lancet paper from the UEA/PHE/GBD collaboration as evidence [Output 1]. The paper was shared in advance with the NHSE CE (S1i) and followed up on release. The PHE Director of Health Improvement emailed that NHSE colleagues were impressed and wanted the NHSE CE and 200 senior NHS executives to be briefed (S1ii). The NHSE CE’s senior adviser emailed Steel regarding the pre-publication of output 1 saying: ‘ Thank you so much. It’s really excellent work, and timing couldn’t be better’ (S1iii). MPs and Peers discussed the LTP and UEA paper in a meeting chaired by The Health and Social Care Committee chair, and the NHSE CE requested further details (S1iv). The Chair of NHSE emailed: ‘ Your data were referred to several times through the day as we worked through the complex strands of the long term plan - many thanks…’ (S1v). The PHE CE wrote in ‘Public Health Matters’ that: ‘… this GBD data … provides a solid foundation for the forthcoming vision document from Secretary of State Matt Hancock on the importance of prevention, placing good health at the heart of all policy making, and of course the opportunities of the NHS Long Term Plan’ (S1vi). ‘Public Health Matters’ also commented: ‘ The work is a partnership between PHE, the University of Washington, the University of East Anglia and many colleagues. This study is incredibly timely, providing a detailed and comprehensive picture of the health of people in the UK just at the time when it can be used to shape the forthcoming NHS long term plan’ (S1vii).

The resulting NHS LTP (S2), published in January 2019, is a landmark policy document. UEA’s Lancet publication [Output 1] was the major evidence source underpinning the plan’s priorities (cited eight times, S2). This touches the lives of everyone in the UK, but especially in areas of multiple deprivation. The UEA research quantified the top risk factors for deaths in England. The LTP (citing Output1), states that: ‘These priorities [smoking, poor diet, high blood pressure, obesity, and alcohol and drug use] guide our renewed NHS prevention programme’ (p33, S2).

The research identified depression as a major contributor to the burden of morbidity and quantified its relationship with deprivation. It clearly identified locations, including Blackpool, as deprived areas with particularly high disease burdens. Citing UEA research [Output 1], the LTP states that ‘ Premature mortality in Blackpool, the most deprived part of the country, is twice as high as in the most affluent areas.’ It goes on to say that ‘NHS England will introduce from April 2019 more accurate assessment of need for community health and mental health services, as well as ensuring the allocations formulae are more responsive to the greatest health inequalities and unmet need in areas such as Blackpool’ (p.39-40, S2).

The PHE Director of Health Improvement wrote that: ‘The analysis presented burden of ill health attributable to individual risk factors in each locality and therefore provided very direct evidence of the potential benefit of addressing those problems in those areas. The paper was therefore an ideal input to the planning and implementation of the NHS Long Term Plan, and it was recognised as such by Simon Stevens the Chief Executive of NHS England… It is probably the clearest example I have ever seen of a single paper directly influencing a planning process, leading to substantial change in services and investment in prevention’(S3i). Referring to clinical priorities set out in output 1 such as cancer, mental health and stroke, the Kings Fund commented: ‘ Perhaps the most striking commitments in the plan relate to a group of clinical priorities, chosen for their impact on the population’s health … These commitments will save lives and improve the lives of patients’ (p4-5, S3ii) and referred to the guiding role of Steel’s research in identifying the top five risk factors as a focus for the renewed NHS Prevention programme (p19, S3ii). The CE of PHE wrote that ‘ Professor Steel and the team at UEA were able to develop an analysis of GBD that was innovative and informative … the resulting paper had a considerable impact on public health practice nationally. It also clearly spoke to local audiences because of the nature of the analyses and the bespoke local messages within the data. We are certain it has helped local Councils set their priorities and make the case for spending on prevention’ (S3iii).

Changes to resource allocations and impact on patients and practice

UEA research enabled the NHS, for the first time, to assess health problems across England in a comparable way, thereby enabling more precise targeting of funds and resources. The Chief Medical Officer (CMO) wrote that: ‘ The research into burden of disease led by Professor Steel and colleagues at UEA and the associated Lancet publication played a vital and unique role in the development of the NHS Long Term Plan by Sir Simon Stevens and NHS England. It provided the evidence base for the overall strategic priorities and the redistribution of resources to areas identified as being in high need, such as mental health in inner cities. The LTP is a key living policy document for the NHS, and as Chief Medical Officer at the time I saw how the priorities that it set out, informed by this burden of disease research, have had and continue to have a lasting impact across the NHS. Examples of the impact range from reducing inequalities in funding for mental health, to raising the profile of musculoskeletal conditions, to renewing the focus on prevention of heart disease and cancer, which remain the biggest causes of death in England’ (S4).

Financial allocations for Clinical Commissioning Groups (CCGs) changed in 2019 to support the LTP implementation in line with the findings from UEA research, particularly around mental health and health inequalities (S5i). For example, to target funding to small areas with extreme inequality, The Advisory Committee on Resource Allocation (ACRA) changed how the standardised mortality ratio is aggregated to an overall CCG weighting. For example, this increased Blackpool CCG’s allocation by 5.13%, or GBP16,000,000 (S5i). To tackle needs relating to mental health, in January 2019 the NHS England Board agreed to meet the LTP commitment to increase mental health spending to GBP2,300,000,000 a year by 2023/24 (S5ii). ACRA improved its estimation of need, leading to increased CCG mental health resource allocations from 2019 in some coastal areas and urban centres with younger deprived populations. This additional resource has already started to increase capacity in practices and benefit patients. For example, in Kent, the NHS used the additional funding to provide new mother and infant mental health care and launch two new street triage services in Thanet and Medway (S6i). Oxfordshire has implemented third sector partnerships to support young people who are hard to engage with traditional services. One family commented: ‘ since we have had the help from RAW [the new service], [name of son] has changed for the better and it’s a pleasure to see him smiling and chatting about his sessions’ (S6ii).

UEA research also identified cancer as a leading cause of premature mortality, and the LTP directly referenced Steel’s finding that that the slower improvement since 2010 in years-of-life-lost is ‘mainly driven by distinct condition-specific trends, predominantly in cardiovascular diseases and some cancers’ (p56, S2). The LTP stated that ‘ We have therefore used these GBD findings to help frame the improvement priorities in the Long Term Plan’ (p56, S2). For cancer, the LTP committed to diagnosing 75% of cancers at stage 1 or 2 by 2028, and to rolling out Rapid Diagnostic Centres (RDCs). In response the York RDC launched in 2020 and has assessed patients through the COVID-19 pandemic. Cancer Nurse Specialist Jo Clark said: ‘ The RDC pathway is personalised, reduces unnecessary appointments and tests and improves delays in diagnosis. I have seen the effects that waiting for tests and results can have on patients so improving this part of the patient’s journey is such a positive step’ (S7i). The new GBP70,000,000 ‘Targeted Lung Health Checks’ programme will fund 10 projects in the areas with the highest death rates from lung cancer (S7ii).

The LTP stated that its improvement priorities for the ‘biggest killers and disablers of our population’ used ‘ the latest epidemiological evidence’, citing Steel et al. It estimated the following impacts:

• preventing 150,000 more heart attacks, strokes and dementia cases (p63, S2)

• 55,000 more people each year will survive their cancer for at least five years (p57, S2).

Policy impact beyond the NHS Long Term Plan:

UEA research has fed directly into healthcare policy beyond the NHS LTP. For example, changes to strategy and indicators relating to musculoskeletal and mental health have been called for. In a report that cited Steel et al [Output 1] several times, the Kings Fund called for ‘ a new strategy on health inequalities …. to reflect evidence about the growing importance of morbidity as well as mortality – especially musculoskeletal morbidity and mental health’ (p51, S8i). The Public Health Outcomes Framework (PHOF) is used to monitor the effects of NHS and public health services on population health. Public Health England’s consultation (p21, S8ii) cited Steel et al showing that back and neck pain was the leading cause of disability, and therefore proposed a new indicator of the ‘ Percentage reporting a long-term musculoskeletal (MSK) problem’ to increase recognition and treatment. This indicator is now in PHOF 2019-2022 (C27, S8iii). The CMO wrote that: ‘ The methodological approach of combining robust comparable burden of disease estimates based on UK data, with England-specific measures of deprivation in small geographic areas is likely to remain central to future NHS Planning, and to be a key tool in providing an evidence base for the recovery from the COVID-19 pandemic’ (S4).

Developing international impact

Professor Steel was invited to describe this UEA research as an example of national policy impact at the World Health Organisation European Burden of Disease Network and also at workshops organised by the European Commission Joint Action on Health Information, which streamlines health information across Europe, where 40 partners in 28 countries have collaborated to share learning from this UEA research.