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

2. How to Decide ?
RCTs and systematic reviews ?

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

4. Complexity : Systems Thinking
Unpredictable Outcomes
Emergent Phenomena
Everything is connected

5. 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

6. 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

7. 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: : /

8. 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

9. 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

10. Self awareness and engagement Brough et al
Self awareness and engagement Brough et al. European Journal of Integrative Health Care 2015;7:
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’

11. 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

12. 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

13. 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

14. Wellbeing Reviews Halton Community Wellbeing Practices

15. Social Prescribing Halton Community Wellbeing Practices

16. 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