Ethics

We sought advice regarding ethical approval from the appropriate committee (North West Research Ethics Committee), and were advised that the project did not require formal review under the terms of guidance for NHS research ethics committees in the UK. This was due to the nature of the sample - NHS employees and policy makers, rather than patients. All participants gave informed consent to take part in the study.

Design

An in-depth qualitative design, employing interviews and focus group discussions and informed by ethnography, was chosen to allow exploration of the meanings and perceptions of participants regarding partnership working against the backdrop of the overall context of decision making in public health policy. It was conducted by a multidisciplinary team with varied backgrounds and experience, including: medical anthropology (LO: main researcher), clinical epidemiology (SC and MOF) and public health (DTR, FLW and MM).

Participants and setting

Research participants were involved in decision making around CVD at a local, regional or national level in the UK. Coronary heart disease is one of the most important contributors to mortality and morbidity in the UK, with well-established organisational frameworks for partnership working and decision-making. Some of these partnerships are specific to CVD, such as the cardiac networks which have a clinical focus [18], and the Heart of Mersey initiative which has a prevention focus [19]. In addition individuals working on CVD sit on a variety of cross-cutting groups working to promote health more broadly e.g. to promote exercise and health eating in children. In this respect individuals working on cardiovascular disease prevention are well placed to comment on the partnership working agenda. The initial sampling frame for the interviews comprised 58 individuals involved in the public health policy and decision-making process around CVD in a range of organisations in England. Two distinct strategies were used to generate this diverse pool of participants: Firstly, a list of known individuals involved in the policy and decision-making process was drawn up on the basis of existing professional networks. Secondly, a purposive sampling strategy explicitly sought to include individuals from organisational types that were under-represented in the initial list of known policy/decision makers' organisations. Subsequently we used theoretical sampling, and we sough participants strategically to refine and test the developing analysis. These lists were then combined to generate the final sampling frame. A recruitment letter was sent to every person on the list – this gave background details and invited the recipient to participate in the study. The interviews took place from November 2009, through to the end of 2010, spanning key events influencing the NHS and healthcare in England [20]. These include the general election in May 2010 and the subsequent publication of the NHS white paper in July 2010 [4], followed by the publication of the public health white paper in November 2010 [3].

Interviews

In depth semi-structured interviews were the main method of data collection. Prior to the interview, participants received an introductory letter, which provided further information about the consultation process, and written informed consent to participate was taken. A topic guide was developed, the content of which evolved as data analysis progressed and the research focus became clearer. The topic guide covered open ended questions about the policy making process; the nature of decision-making across organisations; the use of evidence; and explored barriers and facilitating factors influencing partnership working and the use of evidence across organisations. Partnership working around CVD was used as an initial example, but the key consideration influencing the direction of each interview was the participant's answers to questions in terms of their individual experiences. The interviews were conducted by LO and MM. Table 1 outlines the roles of the interview participants.

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Table 1. Interview participants.

https://doi.org/10.1371/journal.pone.0029536.t001

Focus groups

The three focus group discussions were conducted in order to explore key emergent themes from the individual interviews and to address some of the discrepancies and gaps in the interview data [21]. For each focus group we aimed to recruit between six and 10 participants. After taking written informed consent, participants were presented with a summary of the interview findings and were encouraged to develop and reject the ideas presented to them, providing a method of respondent validation [22]. We took a pragmatic approach to recruitment to the focus groups, and made use of public health events where decision makers were already due to congregate. The first focus group included participants who were involved in decision-making around CVD in one Primary Care Trust and were therefore known to each other. The participants in the first focus group had also taken part in individual interviews, and we were thus able to undertake a process of member checking with this group. The subsequent focus groups were used to test and develop themes further. All participants attending a particular meeting at the PCT were invited to take part in the focus group. The second included participants at a public health conference, and targeted individuals involved in CVD policy were invited to attend the focus group. The third was conducted at a public health training event, where individuals had the option to join in the focus group discussion as a parallel session.

Analysis

The analysis sought to identify associations between themes and to carry out an in-depth exploration of the emergent findings. All interviews and the focus group discussion were recorded electronically and analysed using NVivo software for qualitative data analysis (version 7). The analysis used techniques drawn from the constant comparative method [23]. Transcripts were coded line-by-line based on the meanings, perspectives, and actions which they represented, and for contextual factors in their generation. A subset of 25 per cent of transcripts were double coded by two members of the research team, disagreements and insights were discussed and alternative interpretations were incorporated in the analysis. The analysis was further tested during discussions with colleagues, through meetings of the project steering group, and in the focus group discussions. Through this process, the aim was to identify the “big ideas” (or themes) that were grounded in the data [24].

Validation

DTR, MM and FLW coded a subset of 25 per cent of transcripts as a check to ensure high levels of inter-researcher consistency in analysis. Disagreements and insights were discussed and alternative interpretations were incorporated in the developing analysis [25]. The focus groups were then used as a further source of data for member checking, triangulation, and testing of theories.

Examples of partnership working

Numerous examples were cited of areas of joint working between the traditional health sector, local authorities, academia and the third sector (text box S1).

Benefits of partnership working

In general positive views emerged in relation to working across sectors, and practical examples were provided where mature organisational structures and working groups have been established, around issues with a specific health remit. An important theme was the need for, and clear benefits associated with joint working, in terms of influencing the broader determinants of health, and addressing health inequalities. These respondents expand on these themes:

We have joint commissioning around…well older people. You have got obviously health issues but you have also got social care issues and very often it's the link between the two that gives the best results rather than behaving in silos. It's always been you know a big problem in us actually delivering holistic health care that you don't make the proper links with other agencies that actually make it better for patients

P25 – cardiac programme manager

We have a number of working groups across key areas, co-chaired by someone from health or someone from local authority or someone from another sector…so, we try and forward the, if you like, the preventative end of the public health agenda and to promote health and well-being. And, clearly to try and address the issues of health inequalities.

P35 – NHS/LA joint appointment

Factors that facilitate partnership working

It was perceived important to properly understand the organisations that one was attempting to influence, and to do this required inside knowledge. In this respect, joint appointments were felt to be particularly valuable. This respondent outlines this view clearly:

I think where your host organisation is has a huge impact on your influence. And from my perspective, understanding how the political system works from the inside is so much, so much easier to influence from the inside than it is from the NHS looking in.

P38 – joint LA/PCT worker (health and social care)

Joint appointments between the NHS and LA were also felt to allow the profile of preventative approaches to be more effectively raised within NHS structures.

Partnership networks, both formal and informal have been established in many areas. Key to the success of these groups are clear aims and objectives, and frameworks for decision making and implementation of strategies, as outlined by this respondent:

I mean we are now what's known as a Section 75, which is a partnership agreement with the City Council. So we have an arrangement now where there is delegated functions and therefore delegated decision making…So that we get that joined up partnership working arrangement.

P38 – joint LA/PCT worker (health and social care)

Perceived barriers to partnership working

Significant barriers to joint working were identified, including the inherent complexity of influencing the determinants of health across sectors. These are summarised in text box S2, and described in more detail below.

Barriers – dealing with complexity

Dealing with the complexity of public health decision-making and primary prevention to influence the broader determinants of health was felt by many participants to be very challenging. One theme that emerged was the perception of limited influence at the local level. Decisions were felt to be taken at a national (government) or international (EU) level, with population-wide primary prevention thought only to be effectively tackled through national or international efforts. There was the sense that this could lead to a feeling of being overwhelmed by the complexity of the task, as expressed by this first respondent, referring to a group considering the evidence base for cardiovascular disease policies:

It's a nightmare, god with cardiovascular (laughs) well where do you stop? They look at government policy, national government, regional government, European government, you know economic policy, different types of political and social organisations so you know the breadth of it is immense.

P23 – public health academic

Trying to address the primary prevention agenda, it's obvious that a large part of the agenda has to be addressed at national or EU levels.

S1 – CFGD

Underpinning the issue of complexity were concerns about the difficulty of tracking inputs and outputs over long time frames, using imperfect data, and imperfect tools. This compounded the substantial challenge of sustaining arguments for public health interventions in the face of limited resources. Some participants were concerned about the difficulties of measuring outcomes, and of ensuring that health was considered an important outcome across sectors, where partnership working may also be focussing on other outcomes, such as employment, resident satisfaction or educational performance measures. One participant suggested that public health professionals needed to become more adept at highlighting the health effects of interventions and policies that are under the jurisdiction of other sectors:

I think the other issue, you're possibly touching on this now, is how can we politicise public health as a key outcome that needs to be considered in other policy areas, whether it be transport, whether it be agriculture etc.

P107 – CFGD

But one participant suggested that integrating health into this broader agenda was made more challenging by the perceived lack of a theoretical framework for action across sectors. Speaking in the context of implementing recommendations to increase physical activity, one respondent outlined this issue:

What I never really felt we received sufficiently was a good theoretical framework on which to hang this…how the implementation of the recommendations might be parcelled up amongst sectors or different sort of user groups…

P23 – public health academic

Barriers – Cultural issues

Silo working persists within the current system of partnership working. Prioritisation of different outcomes across sectors was seen as one of the issues driving this, with the acute sector perceived to be primarily interested in short term health outcomes, local authorities interested in social outcomes, and the PCTs trapped in a vacuum between the two. A cardiologist working on a CVD prevention programme suggested that this silo working meant that public health professionals based in PCTs had limited influence:

You know you're well intentioned (Public Health) and you know what to do. But you neither have the medical or NHS connections to enable you to do it nor the social and political connections in order to implement what you want to do. I think that's quite significant in my mind.

FGD – consultant cardiologist

Perhaps symptomatic of this silo working was the perceived language barrier between different sectors, and the use of acronyms and impenetrable specialist terminology, which was viewed as a barrier to effective communication:

When you speak to local authority representatives, it's erm, it's like talking to an alien. And they feel the same to us because we use acronyms in the NHS like QUIPP and DOUGIE all that sort of stuff. So we're trying to get a foot in both camps really as a starter for six

P05 – public health academic

Contributing to the language barrier was the difficulty of reconciling what is good evidence for an inter-sectoral intervention, because different sectors value evidence in different ways. For instance, town planners trusted CABE guidelines (Commission for Architecture and the Built Environment), whereas PCT staff frequently cited NICE and Cochrane. There was a perceived lack of evidence based guidance that spanned sectors. A key issue raised was the identification and packaging of this evidence to persuade policy makers to invest in upstream preventative interventions. Arguments based on economic effectiveness were perceived to be particularly influential.

An exceptionally robust evidence base (is needed) to show that this is robbing Peter to pay Paul effectively in terms of making up cuts at this moment, which will result in a much greater burden on the Health Service.

S8 – CFGD

In the context of a sustainable transport intervention, this participant outlined how the public health community lost the argument, partly because they could not bring to bear the key economic arguments:

So they say like this road will improve congestion and will reduce journey times and we can put a value on people's time…But they weren't very good at valuing the health benefits, and if we're talking about building bypasses compared to getting people out of cars into walking and cycling then that's a major, major part of the benefit

P32 – NHS/LA joint appointment)

Some participants felts that this type of policy relevant evidence was potentially available, but that public health advocates were not learning lessons from other settings.

We need to show how places such as Denmark or New York State have pushed this [trans-fat ban] through in terms of legislation and what evidence they used in terms of persuading policy makers to change their opinion on this….this sort of approach needs to be replicated

S4 – CFGD

The NICE physical environment guidance was cited as an attempt to develop cross sector guidance. However, one of the problems with this was the dissemination and implementation of guidance across sectors:

There was no implementation (of the NICE guidance) to the professional bodies who were expected to implement the health principals we want…So town planning, urban design, architects and transport professionals who work in local authorities…there is no ability to transfer what we've done from a heath sector perspective into their professional bodies and practices

P23 – public health academic

Further complicating the relationships between sectors was the issue of jurisdiction over particular outcomes and the perceived territorial demarcation between organisations. It was perceived that the health sector could be seen to be speaking out of line when making recommendations that could affect other organisations, and that this could lead to politically difficult negotiations:

The interesting thing was within government, the number of agencies who got pretty upset about NICE making certain recommendations. For example, one of was about CAP (Common Agricultural Policy) – DEFRA (Department for Environment, Food and Rural Affairs) went bananas….they got all sorts of comments back saying ‘Well you're the NHS, why are you telling the food industry what to do?’

P16 – public health academic

A key theme that emerged was the systematic undervaluing of preventative interventions, especially in the context of limited resources. Some suggested there was a culture of paying lip service to prevention, leaving preventative initiatives particularly vulnerable to cuts. Furthermore some felt that this was still the case, despite evidence to suggest that preventative interventions could be cost saving:

But in the grand scheme of things, in their list of priorities when cuts are being made and money is very scarce and resources are scarce, prevention isn't gonna be something that's high on the agenda

S127 – CFGD

Everybody kind of pays lip service to it and says prevention is even more important in the current climate, yet at the same time it seems to be the most vulnerable element of the health budget in some respects.

S119 – CFGD

Barriers –Macro level influences

There was the recognition by some that intersectoral working for public health is highly political, and there were powerful lobby groups also trying to exert influence. Speaking about attempts to limit advertising of unhealthy foods to children, and to regulate vending machines in schools, one participant suggested:

There are a lot of competing interests at political level. I think the health lobby are pretty naive and pretty inefficient at getting, you know that kind of political support

P23 – public health academic

Some felt that the current government's focus on behavioural “nudging” - encouraging individuals to take responsibility for their own health behaviours, rather than the government taking the lead in creating healthy environments - was the result of industry influence, and was viewed with skepticism by public health professionals in our study:

Somehow the state was [seen to be] too involved in the past, when I saw it as barely involved at all, and that these are matters of individual responsibility when individual responsibility is absolutely no safeguard against an ecological setting which is designed to overcome individual responsibility.

(P03, public health academic)

Public pressure, expressed by local constituents, was also cited as being particularly important, and this tended to focus on issues of healthcare access, rather than more upstream issues. Reasons cited for this included the fact that debates around acute services tend to be more high profile, and more likely to “hit the headlines”.

Politicians listen to their constituents as opposed to the public health professionals

S122 - FGD

Secondary care services, acute services, tend to dominate the agenda both in the public mind, politically and within Health and Social Care.

P20 - Public health consultant

As outlined above, economic considerations were of paramount concern in the current climate, and it is clear that many feel that prevention is particularly vulnerable, especially given the longer timescales needed to demonstrate benefits:

Interventions of that type at this moment in cash-strapped times are seen as luxury interventions, and the focus has been on operational issues in cash-strapped times

S91 - CFGD

So overall there was the perception that the capacity to shift the balance towards partnership working for health was constrained by a plethora of high level influences. This participant describes the dynamic nature of this complex system:

So we see a very complicated picture, sort of a dance of different interests and different issues at the moment shaping the messiness of policy making…

(P05, public health academic)

The future

In principle the re-location of public health to a local authority setting was felt to be a positive step by some. This participant expressed optimism, suggesting that this move represents a homecoming for the public health function:

So, I think there, there is a lot of coming back together again because planning actually came out of public health and housing really. So that was it's original function – I think it kept the links with housing quite well but it lost it with public health. So, I can only see this, you know, this, er, working together as being a good thing really.

P37 – LA employee

Others saw new opportunities for decision makers at all levels to raise the profile of population-wide primary prevention at a national level, given that the new coalition government has expressed a renewed commitment to addressing health inequalities. However, there was the concern that this will only be met if all sections of government act in a coherent way to address the underlying determinants of health and health inequalities:

There are a lot of issues that reflect on health that require cross-Government working – I think that will be an opportunity with this new administration.

P36 - public health academic

A key concern was that yet another re-organisation would lead to the breakup of established partnerships that have developed over a number of years. In the context of a healthy eating project, involving convenience store shops, one participant expressed concern that projects were not being re-commissioned, just at the point at which they were beginning to deliver concrete outcomes.

It's taken 10 years to get to this point, and many other areas probably won't have had the chance to see the range [of effects]

P30 – LA employee

Participants also suggested that many of the concerns about silo working could equally apply to any new organisational structures. One participant suggested that there was a tendency for local authorities to plan on the basis of small areas, such as neighbourhoods, and that this mitigated against a joined up population approach. Furthermore, there was concern that partnership working on public health issues with GP consortia would be challenging, due to the lack of co-terminosity and governance structures.

I think there will also be challenges because certainly where I work, we're actually working at neighbourhood level so you know, we're gonna be working in even smaller silos

S89 – CFGD

We also worried about the outcome frameworks that are coming out. Because you're gonna have a different one for the Local Authority and Public Health and a separate one for GP Consortiums - there needs to be targets which are the same in both.

S98 – CFGD