Impact on public health practice & policy

Shifting the Gravity of Spending

Researching Priority-setting Tools for Public Health Investment and Disinvestment Decisions.


The notion that public health resources are scarce relative to needs and the demands upon them is not new.  Resources should therefore be allocated in such a way as to maximise benefit for a given level of resource input, or achieve the same level of benefit for a reduction in the amount of resource input.  How best to achieve better investment and disinvestment decisions has long been a challenge facing policy-makers but, following deep cuts to public spending since 2010, the issue has become more urgent and acute.

Since 2012, a group of researchers, some initially based at Durham University, and then at Newcastle and Northumbria Universities with colleagues from the Universities of Sheffield and Kent, have undertaken a number of linked studies exploring the application of priority-setting tools that local authority public health decision-makers might find useful for investment and disinvestment decisions.   Funding for the research has come from the NIHR School for Public Health Research (SPHR) and full details of the early programme of research conducted from 2012-2016 and its findings can be found here and also here under Current Research Projects.

Most recently, a one year study (2017-18) has been completed, also funded by SPHR, evaluating Public Health England’s Prioritisation Framework (PF).   

How the Prioritisation Framework came into being 

Influenced and informed by earlier findings from the Shifting the Gravity of Spending research programme, Public Health England (PHE) recognised that local authorities needed more health economics input to guide them through the prioritisation process.  There was also an acknowledgement of the need to balance tacit, experiential knowledge and political judgement with robust evidence from reliable sources.

Allied to this was a view that elected members would simply ignore the evidence if it did not support their own ideas or the views of their constituents.  It was essential, therefore, that they were engaged with, and owned, the process of allocating resources in new and different ways.  

Underlying the earlier research was the importance of context in all its manifestations – organisational, political and relational, ie in terms of relations among stakeholders.  It had a critical impact on influencing and shaping what happened in practice. There were variable approaches to priority-setting – from the adoption of methods and tools, to discussion and reaching agreement, and a tension between encouraging the uptake of prioritisation tools and their perceived value.

A key finding was that more attention is required concerning the purpose and value of adopting decision support tools and being clear about the types and/or level of decision-making where they might be most useful.

Evaluating the early adoption of the Prioritisation Framework 

As mentioned, the findings from the early research informed the development of PHE’s new Prioritisation Framework (PF).  This was designed to help decision makers decide how public health budgets should be spent and where to invest and disinvest in a structured and transparent manner.  

With PHE’s support, a rapid evaluation was undertaken of three early local authority adopter sites. The purpose of the study was twofold: to explore how far the lessons from the original study had been taken on board in the adoption of the PF by the three sites; and to assess the experience of using the PF in different local authority settings.  The final report can be accessed here.

Key findings

The study yielded rich insights into the use and value of the PF as well as suggesting modifications to its design in order to strengthen its appeal and impact.  All three local authorities adopting the PF acknowledged that it provided a useful systematic framework to structure and guide prioritisation decisions and one that encouraged transparency over investment and disinvestment decisions.  The role performed by PHE in facilitating the process in the three sites was especially welcomed and considered to be critical to the adoption of the PF.     

However, uptake of the PF required a significant investment of time and commitment from public health teams at a time when resources (human and financial) were stretched. The impact of the political environment in local government was a major factor determining the likely uptake of the PF. Ensuring committed leadership and engagement from senior politicians as well as officers was regarded as critical to success.

Next steps

Looking forward, as the PF becomes more embedded and stakeholders become more comfortable with its use, the next logical stage in its development would be to include a modelling exercise to assess impact of budgetary allocations on outcomes at the margin as a key element of the process. In particular, an assessment of change in budget allocation and a modelling exercise to estimate the impact on key outcomes and metrics would facilitate the move towards recommendations/decision- making that leads to both technical allocative efficiency gains.


The issues the PF seeks to address will not go away and a mechanism which provides a focus, and forum, for engaged and informed deliberation about priorities and does so in an open, structured and transparent manner will be required.  To that end, early experience with the PF is encouraging.

Last modified: Tue, 02 Apr 2019 12:38:57 BST