Consultation

Further research is needed to establish how we can promote and create communities that support healthy ageing, independence, and recognise the economic value and contribution of older people. Further research in this area will enable more years spent in good health which will help to reduce health inequalities across different social groups and reduce the growing financial pressure on health and social care services. Particular attention should be paid to LGAs, who continue to shape key policy areas of; healthy ageing, prevention, loneliness and isolation, dementia, end of life care, supporting carers, engagement, personalisation, care and housing.

• The pension-age population is forecast to rise by over a third. This points towards a surge in demand for health and social care services unless health in old age improves dramatically.

• The breakdown of the nuclear family is also going to prove challenging for local authorities. More fragmented families could translate into greater demand for public services as care roles traditionally carried out by family members are left to the state or private providers. The fact that family members will be more widely dispersed will also impact on housing quality and affordability.

• By 2035, half of all revenue from local taxes could be spent on adult social care.

• The gap between disabled people’s employment rate and the rest of the population is about 30%. There is a strong economic case for trying to close this gap. By helping one million more disabled people into work would boost the economy by £13 billion.

The household, work and general build environments need to be designed in a way that supports a broad range of healthy behaviours including food preparation and physical activity. Research will be required to understand how the full range of physical environments can be optimally designed to be accessible to all including those with impaired mobility or vision as well as promoting healthy behaviours.

• A nationally integrated major locality programme looking at how urban design and infrastructure can increase physical activity, improve community cohesion, reducing antisocial behaviours, and improve mental health. Cross sectoral and community-based research would evaluate systematically the natural experiments that exist in our towns, cities and rural areas. Local social environments are predictors of premature mortality and disability adjusted life years with wide gaps between affluent and poor areas. Research questions include: Are these areas modifiable, evaluable and trackable; how can localities work with national level to shift all behaviours in energy consumption, climate adaptation, agricultural and commercial policies with benefits to both population and planetary health.

• Our housing conditions and the area we live in have huge influences on our health, via a range of mechanisms. Better understanding of these mechanisms is needed to remove harmful impacts of housing and maximise the health promoting potential of our homes and neighbourhoods. Factors requiring better understanding include the role of exposure to environmental hazards, the impact of overcrowding and of living alone, how housing insecurity and enforced moves affect health, and the role of the area we live in.

Public health research is not possible without public engagement and trust. This remains a key challenge for the future of public health and it is important that the numerous initiatives in this area are well coordinated and share best practice. Public and patients need to be involved and engaged in research question identification, in research projects and in appreciating research evidence.

• Little is known about the views and values of the wider public in relation to the allocation of resources across population health initiatives or public sectors affecting health inequalities (e.g. education, environment, welfare, social services, transport, health…). There is work to show that the public can engage in questions of priority setting in the context of population health – research is needed to engage and elicit public perspectives, both to progress the conversation and to deliver mandate to practitioners.”

• Develop better evaluation frameworks and measures for community engagement and empowerment that can be used in local commissioning and practice.

• How do the public value prevention of infection, in children and adults?

Major inequalities in health persist and are expected to widen over the next 20 – 30 years. In England average life expectancy in the poorest communities is seven years lower than in the wealthiest, and disability-free life expectancy is 17 years lower. As highlighted by the AMS Health of the Public 2040 report there are large systematic differences in health across several social characteristics, including education, occupation, income, wealth, area of residence, gender and ethnicity, all of which are affected by wider contexts, including the social, political, economic and cultural. We need research approaches that will understand the impact of health interventions on inequalities and ways to measure health inequalities that will feed into policy. As part of this endeavour we need to explore the role of the public health community in addressing health inequalities and to link social science disciplines with public health research to develop a shared agenda.

• We know a good deal about the ways in which health inequalities are manifest, but far less about how to address inequalities in order to impact on health. So-called ‘fifth wave’ public health research should focus on initiatives that address how income, wealth and power impact on health. This might focus on policy initiatives in relation to Citizens Basic Income, welfare rights, redistributive taxation, fair finance as well as social housing, or employment initiatives.

• What is the impact of austerity and welfare reform on risk exposures, wellbeing impacts and inequalities in health? (e.g. universal credit, local government funding cuts).

• What is the interface between health and wellbeing and economic productivity?

• What is the value of food systems that support public health and sustainability at local, regional and national levels?

• The way our food system works is closely connected to the economy. However, understanding the ways in which food systems create both economic and social value better could enable approaches to support the public’s health with connections to the wider determinants of health such as employment, skills, environment, all of which connect to our local and national economies.

• What is the public health impact of EU exit?

• What is the association between macroeconomics for health (fiscal policy) and the health wealth relationship.

• Systematic research investigating the return of investment of public health research and interventions on what the faculty call improving healthy life gain – live well longer, not just younger – should be conducted.

• Can a universal basic income (UBI) for young adults improve self-efficacy, mental health & wellbeing and engagement with education, employment, training and entrepreneurship?

Healthy ageing requires prevention at all stages of the life course. Responses have indicated an appetite for an integrated intersectoral research programme to bring together primary, secondary, tertiary and adult education, work, families and communities to support research for a life course learning approach to health, wellbeing and sustainability.

• How can curriculum development and school engagement with families and communities contribute to how children learn about health, critical approaches to evidence and influence on our behaviours (e.g. commercial and policy environments)?

• What impact do novel educational opportunities, through work-based initiatives, apprenticeships, voluntary sector and use of social media, have to reinforce and maintain positive and reduce adverse behaviours?

• How can inclusion be part of innovation for beneficial technology, can working across arts, humanities and IT co-create for young people for wellbeing?

• What models of working between education settings and partners on risk behaviour improve health, cohesion and reduce violence, drug misuse and antisocial behaviour.

• Developing health literacy in the population is a priority – for both pre-clinical presentations and in multiple languages. An interesting approach would be school-level intervention, for school students to develop their own health education materials particularly videos. Using visual methods and storytelling more would be a good way to develop trans-disciplinary research and male findings more accessible to the public.

• Do children who receive free school meals maintain a healthy living weight/average BMI?

• What impact do condom implementation intervention schemes and/or statutory personal social (relationships and sex) education in schools have on teenage pregnancy.

• How can schools best manage the transition from early years to school and minimise any negative effects on children, especially those from disadvantaged backgrounds?

• How can schools best identify children's mild to moderate mental health needs, and what role can early intervention play in preventing escalation?

• What are the factors associated with teacher and pupil wellbeing, and what interventions and approaches are effective in supporting and promoting wellbeing of all in schools and colleges?

• How can we better quantify and measure the benefits of social work assessment, training and development in terms of child outcomes such as wellbeing and educational achievement?

• What are children’s end-to-end routes through the care system, and how does this impact on later life outcomes, such as educational achievement, wellbeing and labour market outcomes?

The future of public health research should look beyond risk behaviours and target the ‘causes of the causes’ of health inequalities: poverty, social exclusion, social isolation, and disempowerment. This includes consideration for the homeless, secure environments, Black, Asian, and Minority Ethnic communities, rural populations, and coastal populations.

• What are the risk factors for homelessness and the early and upstream interventions within public services that can reduce its impact? What is the link to migration within defined populations?

• How effective are Psychologically Informed Environments (PIE) and trauma informed approaches across health, housing and homelessness services (rather than just within specialist services) in reducing homelessness?

• What is the link between homelessness and migration? In particular (1) what is the extent of the issue and what are the characteristics of this population, and (2) depending on characterisation of the problem, what interventions could work to support people in this situation?

• What are the impacts of welfare reform on health and the associated risks of homelessness?

• What are the impacts of short-term funding across health, housing and homelessness services on those with multiple and complex needs?

• What is preventing individuals who sleep rough from engaging with health services, with particular emphasis on the individual’s behaviour rather than structural barriers.

• What individuals’ behaviours prevent those who sleep rough from engaging with health services?

• What community-centred interventions address social isolation and loneliness to build individual and community resilience?

• Gaining a better understanding of the risk factors that can lead to domestic violence

• What are the drivers of violence, poor health and self-harm in offenders and how can we better predict emerging risks? How does this vary by and offender groups?

• How can stigma associated with mental illness in BAME communities best be reduced?

We need a better understanding of food systems, working in partnership to investigate the biological, economic, physical, agriculture and social factors that shape food choice.

• Promising areas for research include:

  • • What are the key drivers of unhealthy diets within the commercial food system?

    • What levers (both internal and external to the commercial food system) can be identified that might most effectively stimulate change in these key drivers?

    • How can the commercial food system best be engaged in the challenge of system change to achieve healthier diets?

    • What is the potential of interventions that can best stimulate the key levers for change within the commercial food system to achieve population health and economic benefits and health equity?

    • How does the commercial food system respond to external regulation – in terms of compliance, avoidance or other reactions? Are there emergent patterns?

    • How is government policy on the commercial food system developed? Which sectors are most influential?

    • What evidence most influences food policy (science, ideology, public views, economic considerations)? Can we use this information to facilitate more evidence informed policy making?

    • How does poverty impact upon dietary behaviours and health?

    • How can we accelerate prevention of non-communicable diseases via healthier diets and greater activity?

    • How can we decrease inequalities in diet and activity?

    • How do we evaluate and understand the cross-sectoral impacts of multi-intervention strategies to promote healthier diets and greater activity?

    • What are the synergies and antagonisms between components of multi-intervention strategies to promote healthier diets and greater activity, and how do they operate?

    • How can we better identify the generalizable learning from context-specific interventions to promote healthier diets and greater activity?

    • How do we establish more meaningful cross-sectoral collaborations with professionals who have the potential to impact on diet and activity?

    • What works for public health messaging?

    • What is the impact of food production methods on nutrient density and health?

• The overall objective should be to develop a toolkit of interventions that deliver beneficial and sustainable dietary change. Allied to this, targeted diets that meet specific nutritional requirements at particularly vulnerable points in the life-course, should be developed (e.g. high protein diets for the elderly).

• This may require manipulating foodstuffs for improved health benefits through genetic modification or supplementation.

• For these strategies to be advanced researchers will need to work closely with consumers to ensure such measures meet their needs and are environmentally sustainable.

Support the evaluation of health protection interventions by providing a multi-disciplinary resources with a strong behavioural science component and the effective use of technology and innovation. • There are opportunities to exploit large-scale environmental measurement networks and satellite-based remote sensing for public health benefit though integration with health and social data.

• Develop tools and methodologies for rapid evaluation to inform prompt health protection action, including evaluation of outbreak response and control using mixed methods approaches and behavioural evaluations.

• Improve understanding of the risk perceptions and behaviour of the population, patients and healthcare workers in infection transmission and in response to health protection interventions (for infectious diseases and environmental hazards) and use it to inform the design and evaluation of novel interventions.

• How can we better estimate direct and indirect weather impacts on non-infectious and infectious / vector borne diseases?

• What HIV prevention innovations (including digitally-supported) can be sustainable in the current landscape to prevent transmission among key population groups?

• How can the impacts of combination HIV prevention (condom use, HIV testing, PrEP and TasP) be improved using whole-system interventions and evaluations at scale, focussing particularly on key populations (as defined by WHO)? How can this approach help stop new HIV transmission by 2030 across all communities in England?

• How can Hepatitis C virus be eliminated from prison settings?

There is an opportunity to lead the world in facilitating transdisciplinary health justice research that integrates socio-legal and public health perspectives and deploys innovative, transferable, evaluation methods that could support rapid translation and policy implementation.

• How can we better use the law at Micro, Meso and Macro levels to improve population health?

• UK research in both the health and legal domains points to the adverse health impact of social problems that are amenable to legal assistance and the beneficial health consequences of receiving timely legal assistance. Legal assistance for socio-legal problems may mean the difference between ‘stable housing, predictable cash flow, custody of one’s children, employment and access to credit on the one hand, and bad credit, uncertain housing, family separation, unemployment or bankruptcy on the other.

• We need to link advice and health services. While GPs and other health professionals may detect patients suffering from socio-legal issues that are detrimental to health, they are ill-equipped to give advice or assistance about those issues.

• The challenge for health justice research is to evaluate the outcomes of different interventions and models of legal and health service integration.

Mental health research is a hugely important, neglected area within the UK despite increased recognition of the growing burden of poor mental health and the many research gaps that exist. There is huge potential in starting early in the life-course and developing systems approaches to the prevention of youth mental health problems.

• We need greater understanding of how to design and deliver community based non-biomedical approaches to prevention and support of mental health conditions, particularly among young people.

• Design effective and cost-effective population prevention mental health interventions across the life-course and in key settings, taking account of wider psychosocial and physical drivers of poor mental health.

• Provide a better understanding of local community-based interventions that address risk and protective factors for positive mental health.

• How can population mental health (and mental health literacy) be improved using whole-system interventions and evaluations at scale, focussing particularly on disadvantaged neighbourhoods and marginalised groups?

• What interventions improve the lives of people living with and recovering from mental illness?

There is major interest in the health impacts of the physical, social and cultural environment, since 23% of global deaths are due to modifiable environmental factors. Exposure to complex mixtures of synthetic chemicals, pollutants and novel materials, including manufactured nanoparticles, is a growing concern. It has been estimated that long-term exposure to air pollution in the UK has an annual effect equivalent to 28,000 to 36,000 deaths and that the health costs associated with air pollution range from between £8.5 and £20 billion per annum in the UK. Therefore, if we can understand the mechanisms by which air pollution affects health more fully, including the health of people with asthma, we can put in place more effective public health interventions to reduce the risks to health associated with air pollution.

• What are the health outcomes of use of the natural environment? Can we use a range of locations and multiple natural experiments to gather longitudinal data to reveal causal pathways?

• A more systematic investigation of the often reported physical and mental health benefits of exposures to green and blue spaces is needed to determine what factors contribute to the intrinsic benefits of these environments and how these vary among different social groups. This will inform our understanding of the importance of connecting with nature and guide decisions about the best uses for our land- and seascapes.

• Air pollution was also a key health research priority identified by the Asthma UK and Academia Europaea meeting of respiratory experts in Cardiff in November 2018. It is known that short-term exposure to pollution is associated with a reduction in lung function, and that during major air pollution episodes many additional patients with asthma are admitted to hospital with breathing difficulties. The role of long-term air pollution in the development of respiratory illness is currently unclear and should be a major area of research investment.

• What environmental public health interventions can be identified and developed to support local and strategic decision-making? What is the scope for taking into account co-benefits across the system and differing time scales?

• How can we better understand the epidemiology and estimate the health impact related to weather and future climate change (including mental health and health inequalities) to ensure that new challenges are considered?

• How can social and behavioural sciences support the development of effective environmental public health policies and advice, ensuring their impacts are fair and non-discriminatory for all of society?

• What are the tangible impacts (both positive and negative, including population movement, invasive vectors and health economic impacts) of environmental public health interventions (e.g. air quality, heat/cold, flooding, housing, built environment, light)

There is strong evidence that future public health should aim to balance personalised prevention and monitoring with population-wide approaches. In the past, prevention research has been overly focussed on developing interventions aimed at the individual. This approach has had some success but arguably diverted attention away from the upstream determinants of population health and a more nuanced complex systems perspective. Nevertheless, research on precision/targeted prevention is still valuable when combined with structural, population-wide measures to maximise its effectiveness.

• We should capitalise on the UK’s extensive infrastructure of population cohorts, which are often extensively genetically and biochemically characterised, and augment this analysis by encapsulating lifestyle factors (such as physical activity, sleep patterns, dietary choices) and social and other environmental exposures (air quality, noise and workplace) and characteristics (such as age, education, income, gender, ethnicity).

• This will help to develop more precise and informative health risk profiles (beyond genetic risk scores) to guide better development and targeting of preventative interventions.

• The use of technology to support individuals in taking greater responsibility for their health has enormous potential; however, it needs to be developed hand in hand with an understanding of individual agency and the wider social factors that determine use, or it risks increasing existing inequalities.

• We also need to provide support to policy makers and those commissioning interventions to evaluate the impact and effectiveness of their decisions. We need to encourage a culture which routinely embeds evaluation from the outputs to assess the impact. Given the long-term nature of public health interventions, which can be challenged by political change and stretched public funds, clear evidence that demonstrates impact and value is be vital.

• A major barrier to progress of the risk reduction evidence base is the inconsistency of methodology, a lack of standardization of definitions, terminology and outcomes. This can hamper the pooling or comparison of data from different sources for additional analyses. Given the costs and long timescales associated with risk reduction studies, particularly randomized control trials (RCTs), it is difficult to compare long-term studies due to the wide variation in inclusion and exclusion criteria, methodology, clinical instruments, intervention and duration of interventions, observations and outcomes.

• There is a need to support junior investigators, as future research leaders, to develop the multidisciplinary methodologies and approaches.

At the advent of the 4th industrial revolution, with the increasing fusion of the physical, computational and biological sciences, the UK has a time-limited opportunity to harness existing (but fragmented) routine, research and digitally generated personal data to deliver predictive, preventative, personalised and participatory public health research.

• Accurately assessing the exposure profile of individuals (in real time) is essential to quantifying the health effects of different environmental constituents, and the use of sensor networks, linked through the Internet of Things (IoT), has huge potential in aiding the development of better models of health impact.

• What is the on-the-ground value (or harm) of new technologies including social media

• Which existing population-based data sources (existing cohort studies) and new sources of big data relevant to ill health and work could be utilised to develop further inference on the incidence and prevalence of occupationally caused ill health.

• Collate evidence to explore the opportunities of and barriers to increased and improved digitalisation in local government

• Exploring how service integration strategies and also innovative technology (machine learning, artificial intelligence, the internet of things, robotics etc) can help ease pressures on services such as adult social care.

• What are the benefits and risks of adopting new technologies to deliver services?

• How can existing research evidence be made accessible and useful to frontline services? How cost effective are different communication and engagement methods?

• How can government make best use of its data to identify users with multiple complex needs? How can integrated service provision improve outcomes for these individuals?

• How do we develop public services that allow users to collectively create their own solutions?

• What role can social movement and network theories play in helping to improve public sector services and drive large scale system change?

• How should Public Health organisations encourage open data publication while minimising re-identification risks (the Mosiac Effect)?

• How should Public Health organisations balance intellectual property with reproducible research in order to enable efficient digital innovation?

• How should Public Health organisations maintain trust and accountability in using AI and machine learning?

The burden of occupational illnesses is considerable for the individual (ill health, direct costs), workplace (presenteeism, absenteeism, premature loss from the labour market), the health service (assessment and treatment costs) and the wider society (loss of tax revenues and reliance on benefits). Research is needed to identify ways we can improve the impact that businesses and work have on population health, wellbeing and sustainability through environmental design, commercial determinants, working practices, fiscal and legal frameworks.

• How can productivity and health, including brain health, be maintained as the workforce ages through changing work practices and environments?

• What is the impact and consequence of work-related ill-health on the individual and society as a whole (including, human costs, costs of ill-health and impacts upon productivity and employment); and how do Government departments with responsibility for health work best together to prevent ill health caused by work?

• Can the HSE stress management standards be successfully used and evaluated in the NHS?

• How will the future burden of chronic disease be influenced by workplace and demographic change?

• Is there an integrated occupational and public health (including occupational health) care pathway that streamlines the identification of new cases of illness, but that also permits access to data that will enable preventative interventions to be strongly evidence based?

• Is there an intervention that could be delivered and evaluated in workplaces to improve workplace nutrition and thereby contribute towards the government's strategy for tackling obesity?

• Better evidence is needed about how the commercial environment, which includes advertising, promotions, planning and licensing practices shape people’s environments, their actions, and ultimately their health; and how these mechanisms can be used to positively impact health, over and above removing harmful impacts.

• This requires close working with government and local authorities with a multitude of potentially positive outcomes for the workforce, the excluded, local communities and wider population.