Better Mental Health for All: Strengthening Public Health Practice Evidence and Evaluation Mike McHugh and Chris Nield

How to Decide ? RCTs and systematic reviews ?

How to Decide ? RCTs and systematic reviews ? In the field of health promotion RCTs are inappropriate, misleading and unnecessarily expensive WHO 1996

Complexity : Systems Thinking Unpredictable Outcomes Emergent Phenomena Everything is connected

Randomised Controlled Trials Sarah Stewart-Brown Why Foundation Years Matter 6/25/2019 Randomised Controlled Trials Aim to isolate the effect of a single therapeutic action or causal factor on a single problem, condition or disease Are not well suited to estimating effects when complex causal pathways are involved Participants need to engage in intervention for it to work several different agents or conditions need to interact together to create the conditions for change effects of intervention are holistic RCPCH FPH DH 9th Nov 2011

Different approach to ‘evidence’ needed RCTs are not a good way of assessing influences on complex systems: ‘Control’ influences the way the complex system works and therefore RCTs do not assess what happens in real world Individualised care can’t be standardised The need to randomise patients interferes with the need for engagement in own health care

Family Links Parenting Programme RCT in South Wales Small qualitative study of consenters and refusers Refusers more likely to be concerned about their children’s behaviour and really want to go to the programme Consenters more likely to take part because: ‘my friend was coming’ ‘my health visitor said I should’ It’s a good programme and I wouldn’t want it to be discontinued’ Stewart-Brown S Anthony R, Wilson L, Winstanley S Simkiss D, Stallard N, Snooks H. Should randomized controlled trials be the ‘gold standard for research on preventive interventions for children. J Children’s Services 2011; 6:.228 - 235: 10.1108/17466661111190929

RCTs of Parenting Programmes Engagement versus equipoise To be engaged You need to take control of your own destiny To consent to take part in an RCT You need not to care whether you get one treatment or the other

Different outcome measures needed To capture: Change in a wide variety of interrelated disease manifestations and symptoms, and aspects of health and wellbeing Including some that were not part of the presenting complaint Change in awareness of health and self care In contrast to: Change in a single disease outcome or disease marker

Self awareness and engagement Brough et al Self awareness and engagement Brough et al. European Journal of Integrative Health Care 2015;7:172-183 Its given me a new set of tools to have a relationship with myself, so that now I know that I can befriend myself ‘ ‘I now feel in touch with my moods and if angst arises I have appointments when I feel the need’ ‘I have learnt to listen to guidance from my own body’ ‘I have reconnected with my own intuition’

How to Decide ? RCTs and systematic reviews ? In the field of health promotion RCTs are inappropriate, misleading and unnecessarily expensive WHO 1996 Realist Evaluation: pragmatic, intuitive, iterative approach? Build on strengths The art of the doable Evaluate and adjust

Rolling Out Evidence Based Programmes Scaling up interventions depends on Local enthusiasm Local skills Local interpretations Use local knowledge and local skills But do need to base investment on research And do need to avoid reinventing the wheel

Community Wellbeing Practice Initiative commissioned Halton Clinical Commissioning Group Over the course of 30 months we have delivered 4,990 interventions to 3,204 unique beneficiaries, working with all 17 GP Practices in the borough to embed a social model of health to complement primary care services. Community Wellbeing Practice interventions include Wellbeing Reviews, social prescribing, community resilience events and volunteering opportunities

Wellbeing Reviews Halton Community Wellbeing Practices

Social Prescribing Halton Community Wellbeing Practices

Summing Up RCTs still regarded as gold standard by health commissioners RCTs do not give precise answers for interventions in complex systems There are other ways of knowing whether something is helping Local authorities more pragmatic