Title: Exploring the use of economic evaluation as a support tool for public health decision making: the case of childhood obesity services
Funder: Department of Health and Social Care

Abstract: Local authorities are now responsible for commissioning a range of public health functions and at a time of unprecedented financial pressures, are faced with making difficult resource allocation decisions. Economic evaluation can assist decision making by expressing the costs and benefits of alternative uses of the money, and whilst there is evidence of these methods being used at the national level, there is little evidence of them being used at the local or organisational level. The key aim of this research project is to work closely with local authority decision makers, to understand what economic evidence would be most useful to support decision making at this level, and to refine the methods accordingly. This will be done using childhood obesity services within the City of Birmingham as a case study. Rising levels of obesity presents a major challenge for public health due to the complex, multi-causal, systemic nature of the problem. The prevalence of childhood obesity in the UK has markedly increased and in Birmingham, 24% of children are overweight or obese in reception, rising to 40% when children are 10-11 years. In 2013, the local authority in Birmingham implemented a school-based obesity strategy, a multi-faceted package made up of cooking workshops, nutritional advice, staff training as well as physical activity programmes. Using established as well as novel methods within economic evaluation, this project will conduct an in-depth evaluation of the cost-effectiveness of these services. At the same time, a formal assessment of the usefulness of the economic evaluation from the decision maker perspective will be carried out focusing on how the costs and benefits are measured and presented. This will be done using a checklist developed with the decision makers at the outset. The research project will be split into the following work packages (WP): WP1: Using qualitative methodology, key meetings at the local authority will be observed to gain a deeper understanding about what economic evidence is used within current decision making, how that evidence is used, and to generate themes for an initial checklist to be developed in WP2. WP2: Using a 'Delphi' approach, a checklist will be developed to assess the usefulness of economic evaluation from the local decision maker perspective. First, local decision makers will be interviewed and asked to rate items on the initial checklist from WP1, and encouraged to suggest new items. Next, national decision makers will be surveyed to rate the refined list of items. This checklist will then be used in WP4. WP3: Using a variety of methods within economic evaluation, an evaluation of the school-based obesity services will be conducted. The data used to inform the evaluations will come from a set of surveys and case studies, along with quasi-experimental methods taking account of the 'natural experiment' setting. The evaluations will then be presented in a form so that the decision makers can clearly see the different approaches and provide feedback on the usefulness. WP4: Using the checklist, decision makers will be asked to formally assess each type of evaluation in WP3. This research will determine the barriers to the uptake and use of economic evaluation for decision making within local authorities. It will conduct an in-depth economic evaluation of Birmingham school-based childhood obesity services by applying both established and novel methods which take account of the 'natural experiment' setting which are common in the public health context. It will produce a formal checklist that can be used by decision makers to feedback on the usefulness of the different component parts of economic evaluation, which can then be used to further refine methods that fit with local decision making needs.

Lay abstract: Since 2013, local authorities have been in charge of funding public health services. During this time, money has been limited and decision makers have been faced with increasing financial pressure to ensure that the limited money is spent in the best possible way. Health economics can assist with this, and can help decision makers by providing detailed information about the costs and benefits of different uses of the money. To date however, it has been shown that health economics is either not used at all, or used very little by local decision makers. This project is about assessing why that is the case, and working closely with decision makers to develop and refine methods that can encourage more use of health economics. This will be done using childhood obesity services within Birmingham as a case study. Childhood obesity is a growing problem in the UK, in Birmingham, 24% of children are overweight or obese in reception, rising to 40% when children reach the age of 10-11 years. In 2013, all primary schools within Birmingham implemented childhood obesity prevention services including cooking workshops. programmes to encourage healthy living, and staff training. Little is known about how effective these services are, and to what degree schools have implemented these services, and how popular they are with staff, children and the families. To assess the value of these services, a detailed economic evaluation will be conducted, using a variety of different methods to measure costs to the health service, to the school, and to the families of the children that take part. At the same time, 'value' will be measured, using methods within health economics that go beyond just measuring weight outcomes, but aspire to measure the wider benefits of the services such as improvement to a child's self esteem, increased confidence, having the opportunity to share views and experiences. This type of 'value' will be measured using new methods within health economics so at the same time, an assessment of how appropriate and acceptable these methods are to the schools and families involved will also be done to inform future methods. A key aim of this research is to assess how health economics can support funding decisions within local authorities. The results of an economic evaluation can be expressed in different ways and to help understand which parts are the most useful, a 'checklist tool' will be developed with the decision makers for them to use at later stages of the project to 'score' the usefulness of different types of information.The programme of work will be split into four stages: 1. To fully understand how funding decisions are currently made within Birmingham local authority, a set of key meetings will be observed. This will help to determine how and where the methods of economic evaluation would be most useful in this decision making process and will generate themes for the next stage of the project. 2. To formally assess how helpful health economics is for funding decisions, public health decision makers will be interviewed at Birmingham local authority and surveyed at the national level to generate a checklist that breaks down each component part of an economic evaluation for decision makers to then subsequently score how useful it is for decision making. This stage of the research will use methods based on the 'Delphi' approach which is a formal approach for combining views from different people. This checklist will then be used at later stages of the research. 3. An in-depth evaluation of the childhood obesity-prevention services will be undertaken to measure the costs and benefits of the service and to communicate that information, using different methods, to the decision makers. This stage will use a variety of methods within health economics, some of them new and emerging to deal with the challenges of measuring outcome when a project has not been set up under formal scientific conditions such as a clinical trial.4. Using the checklist tool developed in the earlier stages, the local decision makers will score the evaluation conducted in stage 3 and provide feedback on how helpful the information was to assist decision making. As well as academic presentations, to ensure all parties benefit, plain English reports will be written for all parties as new results emerge. A feedback workshop will take place at the end, inviting contributions from national and local decision makers, and health economists to understand how the methods can be refined to more fully assist public health decision making within local authorities.

Research activity codes: 8.4 RESEARCH DESIGN AND METHODOLOGIES (HEALTH SERVICES)
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;METABOLIC AND ENDOCRINE;ORAL AND GASTROINTESTINAL;STROKE