Public health priority setting on a national scale: The Scottish experience

Abstract

Objectives

Scotland has the lowest life expectancy in Western Europe and significant health inequalities. A national review of public health in 2015 found that there was a lack of coherent action across organisational boundaries, inhibiting progress. This paper describes a rapid (four-month) systematic approach to prioritisation of Scotland's public health challenges, which was evidence-based, transparent and made use of significant stakeholder engagement.

Study design

Cross-sectional survey of stakeholders in deliberative meetings.

Methods

An independent Expert Advisory Group (EAG) was formed to develop a typology of public health priorities, a long-list of potential priorities and ranking criteria. Deliberative stakeholder events were held at which the criteria were refined and priorities scored by participants from a wide range of stakeholder organisations.

Results

The proposed typology identified three types of public health priorities: risk factors, social factors and system factors; medically defined disease entities were not used deliberately, to facilitate broad stakeholder participation. Fifteen criteria were identified to help identify priority issues, based on the scope of their burden, amenability to change, and multi-stakeholder preferences. Six public health priorities were selected by the EAG based on stakeholder scoring of a long-list against these criteria.

Conclusion

Prioritisation is important in modern public health but it is challenging due to limited data availability, lack of agreed evidence on effectiveness and efficiency of interventions, and divergent stakeholder views. The Scottish experience nevertheless shows that useful public health priorities can be agreed upon by a wide range of stakeholders through a transparent, participatory and logical process.

1. Background

Scotland is a country of around 5.4 million people. Relative to the rest of the United Kingdom the burden of disease is high [1]. Scotland has the lowest life expectancy in Western Europe and significant health inequalities exist between socio-economic groups, which have largely persisted without reduction for over two decades [2,3]. The provision of health services including public health is a devolved issue over which the Scottish Government has had control for over more than two decades, and the health system of Scotland is distinct from that of the rest of the United Kingdom. The National Health Service (NHS) remains a state-provided service with a public health service that is administered by fourteen regional Health Boards, each with a Director of Public Health and dedicated staff providing the core range of public health services including health promotion, health protection and healthcare public health.

In 2015 a national Public Health Review was conducted to better understand the lack of progress in improving population health [4]. Amongst other recommendations was the identification of shared priorities and to deliver action in a more coherent manner across the ‘whole system’ of healthcare and public health. This was particularly about closer working between local authorities and the NHS. This led to a recommendation that a single set of public health priorities be determined across Scotland and that a national public health agency be established, which was launched in 2020 as Public Health Scotland.

The Public Health Reform Team (PHRT) was established in Scottish Government to implement this policy direction. This team was drawn from national government, local government and the health service, reflecting the desire for public health to be thought of as a whole system issue, rather than an issue to be dealt with by any individual agency. Reaching agreement on shared priorities across these agencies was an essential early task in the reforms.

This paper is aimed at Public Health practitioners and policymakers facing the challenge of setting priorities for local or national public health agencies, through a transparent, participatory, rapid (i.e. finished within six months) and low-cost process, based on scientific principles. We emphasize that the prioritisation process described cannot be considered “research,” but rather represents a practice-based attempt to apply scientific thinking to the very constrained planning challenge we faced, which we suspect is not infrequent elsewhere.

2. Methods: The process of prioritisation

2.1. Principles

The Public Health Reform team was determined to approach the priority-setting process in a structured way that ensured evidence was considered from a range of diverse sources. It was imperative (and indeed stipulated by the chief project stakeholders, the Scottish Government and the Scottish Council of Local Authorities) that the process be used to engage as wide a group of stakeholders as possible in the priority setting process with the twin aims of: first, incorporating real-world experiences and evidence into determining Scotland's most pressing public health issues; and second, ensuring that there was wide understanding of and buy-in to the priority setting process, as an early step in the wider reform programme.

2.2. Advisory group

An expert advisory group (EAG) was formed at the request of the Scottish Government and chaired by the senior author, who was selected based on his broad expertise in public health and strong networks across public health policy making and practice. EAG membership came from senior leadership positions in public health, local government and academia which were invited participate. The group was deliberately selected to provide broad representation of the key institutional stakeholders in the new Public Health Scotland, launched shortly after this process was completed.

This group was tasked with proposing an approach to prioritisation, including examples of some public health problems in Scotland that would be suitable priorities, and a set of evidence-based criteria that could be used to select top-ranking items.

Practical and research support was provided, at no cost (i.e. without a project grant or consulting fee) by the Scottish Collaboration for Public Health Research and Policy (SCPHRP) [5]. The EAG met three times in total in November and December 2017, and the entire prioritisation process was completed by spring of 2018. Business was transacted in person, by teleconference and by email.

2.3. Rapid review of relevant published literature

Due to both time and resource constraints, a limited literature search was conducted via Google Scholar, using search terms related to (public/health system) health priorities and priority setting. Fortunately, we found that Marks et al. [6] had conducted a Rapid Review of methods of/approaches to the prioritisation of not only public health problems, but also the social and other challenges for which UK Local Government provides services. Their overall conclusion reflects precisely what our team found in our own rapid review: most of the formal methods of prioritisation across diverse public services -- and/or the public section problems those services tackle -- are technocratically complex, requiring advanced quantitative scientific training (typically in health economics), large volumes of detailed population-based data on health and social problems' magnitudes, costs, and the relative cost-effectiveness of available relevant interventions. This methodological complexity has the predictable consequence that such approaches are not well suited to broad participatory involvement in the prioritisation process, which was insisted on in our project from the start, by its key stakeholders. Perhaps most telling of all, Marks et al. ended up using a purely qualitative approach in their evaluation of their own prioritisation process, interviewing 45 diverse key informants representing the diverse organisational elements, service programmes, and professionals in Local Government in the study setting.

A particular challenge for this project was the requirement, for the use of nearly all these formally quantified methods of prioritisation, for large volumes of very detailed and up-to-date population health data – for example, costed Burden of Illness calculations for the Scottish population. While a formal Scottish Burden of Illness study was nearing completion, by the predecessor agency of PHS (Scottish Public Health Observatory/NHS Health Scotland), it did not include explicit costing of the major causes of premature death and disability, which are essential for the application of standard health economic methods for determining health priorities for a population, and was in fact not published in a peer-reviewed journal until 2021 [7]. It was, however, invaluable as the epidemiological foundation of the prioritisation process which the EAG developed, as described below.

2.4. Defining a public health priority

Clarifying understanding of what a priority is, and what it is not, was the first task of the EAG. Following discussion, the EAG proposed a typology of public health priorities. In this typology, a public health priority could fall into one of three categories (see Table 1 for specific examples of each category):

• 1.Risk factors for ill health (including health behaviours and a small number of broad “disease states” with major population burdens);
• 2.Social and environmental factors: the wider socio-economic determinants of health including education, income, housing, connectedness to others as well as the physical environment (including climate change), and others;
• 3.System factors including how our social, health and other public sector services are organised, including health protection activities and “healthcare public health” (largely clinical preventive) services, and others.

Table 1.

Priority definition and long-list.

Definition: Public health priorities for Scotland should be current problems that are important, amenable to change, with broad stakeholder agreement that they should be tackled now.
Health behaviours/risk factors/disease states	Wider socio-economic/environmental determinants	Systems and services
-Diet and its determinants	-Poverty/Income/Welfare/Tax	- Early years
-Obesity	-Educational Attainment	- Maternal and pre-conception health
-Physical activity	-Housing and homelessness	- Screening
-Smoking	-Green space	- Health and Social Care Integration
-Alcohol	-Air pollution	- Primary Care Services
-Drug misuse	-Social connectedness	- Community health services (e.g. Health Visitors, Community Health Nurses)
-Breastfeeding/attachment	-Quality of work/meaningful activity	- Active travel
-Mental health	-Physical environment	- Work-and-health-related services (including employability)
-Learning disability	-Climate change	- Communicable diseases control (including antimicrobial resistance)
-Healthy ageing		- Vaccination
-Oral health		- Data and knowledge to improve health

The EAG felt it was equally important to specify what a priority should not be, in order to make the task manageable. For example, the EAG recommended that a public health priority should not be a specific disease. The consensus was that epidemiologically-validated risk factors – many of which are linked to a variety of common chronic diseases and can be clearly expressed in plain (i.e. not medical/technical) language – provide a clearer basis for concerted public health action. In the end, a small number of broad ‘disease groupings’ were included in the first column of Table 1 (e.g. “obesity”, where the causal risk factors are very diverse and/or poorly understood, but the burden of illness and disability is clearly very large [7]: e.g. mental health including suicide [8]; learning disability [9]; oral health [10]. Thus, the first typology category described above was expanded to encompass both risk factors and key “disease states,” rather than specific medical diagnoses. The EAG also felt it vital, in order to break from the predominately medical model of public health, that Scotland focus on the fundamental determinants of population health, rather than the clinical endpoints of those influences. [For a more fulsome discussion of how population health is defined, see McCartney et al. [11]].

In addition, the EAG recommended that prioritisation should be about identifying problems, not solutions, therefore specific programmatic and policy approaches were not considered suitable as potential priorities. The underlying assumption of this approach was that once problems are prioritised then local public health partnerships, Public Health Scotland, the Scottish Government, and other stakeholders could begin to discuss how best to tackle these.

A long-list of priorities was then generated along the lines of the guidelines above. These draft priorities are set out in Table 1. The EAG sometimes found it difficult to achieve consensus on both the line-items in this long-list, and also their categorisation into the three columns of Table 1. Existing conventional wisdom on this was mostly helpful. For example, many public health professionals in the UK – and the 2015 Scottish Government Review of Public Health in Scotland [4] (page 9) – have traditionally categorised their main tasks as spanning “health improvement” (sometimes including “health promotion”); health protection (typically including all aspects of both infectious disease control and measures to reduce adverse health effects from toxic-substance or physical exposures); and health services improvement (also sometimes called “public health healthcare” -- a peculiarly British term, not used in North American public health or elsewhere.) The EAG found this categorisation to be unhelpful -- more driven by the administrative labels attached to various public health professionals’ job descriptions, rather than population-level health problems. In Table 1, we consigned such traditional public health programmatic activities to the third and last column, headed “Systems and Services” as a compromise between giving them a higher “billing,” versus leaving them out entirely.

The EAG was very much aware that some of Table 1's categorisations, and indeed the specific phrasing of the three column titles, could be considered rather curious, and indeed hard to justify scientifically. However, we found it necessary to compromise here between a much large set of over-arching categories that the three listed – which we felt would have further complicated the entire prioritisation process – and the lumping together of truly disparate potential priorities.

In the end, the EAG came to believe that the precise categories decided on (i.e. the column headings of Table 1) and the specific line-items within them were not critical to the prioritisation process. It was more important that this long-list, from which the final priorities were to emerge after a broadly participatory deliberative process, was sufficiently inclusive of health problems, challenges and issues that the diverse stakeholder constituencies felt comfortable that their perspectives were respected. This was achieved by circulating this long-list widely (but, of necessity, rapidly) for comment, among key informants working in those stakeholder organisations, before its finalisation.

2.5. Criteria for prioritisation

The next step was to derive a single set of prioritisation criteria against which these multiple types of priorities could be considered. The aim was also to have wide engagement on these shared priorities but with enough focus to clearly define the priority. A fifteen-member Reference Group was asked to comment on the initial draft of the criteria. This group was made up of members nominated by the Steering Group, who collectively were very familiar with senior staff spanning the key stakeholder organisations in the prioritisation exercise: local government, NHS/public health professional, academic and voluntary sector backgrounds. Their feedback was incorporated into the final list of criteria. The proposed criteria are presented in Table 2, together with comments on each, particularly regarding the justification for its inclusion and any major issues in actually operationalising it.

Table 2.

Criteria for comparing potential priorities.

Headline Question	Sub-questions
1. Is this priority an important public health concern?	1.1 What is the current ‘size’ of the problem? (e.g. its “burden of illness,” expressed in DALYs or similar standardized units.)
	2. 1.2 How has the problem changed and how might it change in the future? (i.e. Is the problem clearly getting bigger over time, which would increase its priority, ceteris paribus.)
	3. 1.3 What would happen if we disinvested in this area? (i.e. What are the likely consequences of abandoning related, traditional PH activities – for example, in Health Protection generally, this was strongly felt not to be an option, although that topic did not emerge in the final priority list, which is ironic in retrospect, given the subsequent advent of COVID-19.)
	4. 1.4 What are the wider impacts? (e.g. increases in child and youth obesity are well known to lead to adverse psychosocial sequelae, not merely physical ones.)
5. Can we do something about it?	2.1 Is this issue amenable to prevention by known effective measures? (This consideration is a sine qua non for prioritisation, since many important public health problems—e.g. schizophrenia – are currently not preventable, and public health is not primarily responsible for treatment and support services for those patients.)
	6. 2.2 Are the measures relatively efficient/cost-effective (I.e. a competitive use of resources)? (This is a standard health-economic consideration in prioritisation, but often rendered unhelpful due to the lack of high-quality, convergent studies quantifying the precise cost-effectiveness of public health interventions.)
	7. 2.3 Would action on this priority reduce health inequalities, or risk worsening them? (Recent literature emphasises the potential for public health interventions to increase such inequalities, often inadvertently13.14)
	8. 2.4 When might we expect to see results? (This is a frequently neglected aspect of prevention intervention effectiveness, leading to potentially unrealistic expectations of early impact – e.g. HPV vaccination of preteens.)
	9. 2.5 Is there scope for innovation on this priority? (This is a standard element in all Scottish public sector thinking, included in all policy documents as highly desirable.)
	10. 2.6 How can communities be empowered through this priority? (Similarly, this consideration lies at the heart of many Scottish public policies since devolution began in the late 1990s [9].)
11. Is there the potential to do something about it? (More detailed discussion of these criteria is found in the two next pages of text.)	3.1 Do the public prioritise this issue? (This is important for the same reasons noted immediately above – but notoriously difficult to measure accurately without a complex engagement process that goes well beyond simple public opinion surveys, as shown by the findings of the 2015 Review of Public Health in Scotland [4] which ended up identifying public concerns mostly related to clinical services delivery, not public health.)
	3.2 Do local government prioritise this issue? (Obviously critical, but also a “moving target” as governments change priorities frequently.
	3.3 Do the professions who will likely work on it prioritise this issue?(Also critical, although rarely measured formally, e.g. by targeted surveys)
	3.4 Does the Scottish Government share the aims of this priority? (Same comment as for #3.2 above)
	3.5 Is this best addressed by a joined-up approach rather than one agency? (This is a reasonable criterion for this particular priority-setting process, given its hosting by a partnership between Scottish national and Local Authority governments – but it is difficult to operationalise.)

The EAG was fully aware that it was easy to quibble scientifically and logically with some of the prioritisation criteria below. However, it found that tracking the precise rationale for the final phrasing below was impossible in the context of a necessarily hurried consultation with the very diverse 15-member Reference Group, the members of which did not always converge in their views. In those cases, the EAG itself felt compelled to put forward the best compromise possible, while respecting as much as possible the concerns of the Reference Group.

2.6. Mapping evidence onto criteria

Where possible it was proposed that standardised measures be used as an indication of the size and trend of potential priorities (criteria 1.1, 1.2). In Scotland, data on Disability-Adjusted Life-Years (DALYs) were available for individual risk factors through the Scottish Burden of Disease Programme1 [7,14]. Efforts to estimate DALYs associated with more complex socio-economic factors, and system factors, were considered more challenging and it was recognised that the relative importance of priorities could not always be assessed in a quantitative way. Disinvestment (criterion 1.3) was included as a test of de-prioritisation. That is, it was included to counter stakeholders’ likely propensity to identify most if not all public health issues as meriting attention. This criterion was included as a prompt to help identify problems that had, for example, either already received disproportionate investments in the past, or for which investments had not translated into significant population health change. Action to improve some priorities would be more likely to have knock-on effects on lower priorities and therefore an assessment of the wider benefits of each potential priority was included (criterion 1.4).

In terms of the potential to make improvements, the EAG identified a circular problem. A potential package of measures would be required to assess this, but the aim was to prioritise problems, not solutions. Furthermore, it would not be possible to know if such a package would be adopted, and precisely how it would be implemented. It was proposed that the potential modifiability of identified priorities would have to be gauged by the tacit knowledge and lived experience of the broader set of participants to be recruited into the next stage of the prioritisation process (see below). This element of the criteria included an assessment of the potential equity of impact (criterion 2.3), as it is well known that many courses of action risk widening rather than narrowing health inequalities [12,13], despite best intentions. In addition, the relative cost-effectiveness of action should be assessed (criterion 2.2) although there it was recognised that there is limited robust evidence for the majority of public health interventions, and often considerable scientific disagreement about the precise “cost per quality-adjusted-life-year gained” of even well-defined interventions [15]. Finally, the time horizon for any results is also of importance (criterion 2.4) as politically a mixture of short-term gains and longer-term goals would be preferable for obtaining broader public and government support.

Last but not least, the most subjective element was assessed: whether there was an appetite for action amongst stakeholders. The priorities selected needed to resonate widely with the following constituencies: the public; Local Government; the Scottish Government; and the professional workforce tasked with undertaking the legwork to bring these priorities to the fore of Scottish public health policy and practice (criteria 3.1 to 3.4). Consideration was also given to the likelihood that any potential priority could galvanise forthcoming public health reform efforts in Scotland. The overarching aim of the Scottish Government and Convention of Scottish Local Authorities public health reform programme, launched in 2015, was to innovate in public health, and to “make public health everybody's business” — therefore it was proposed that priorities should reinforce new ways of working, be suitable to be tackled in new ways, and contribute to community empowerment. In Scotland the Community Empowerment Scotland Act emphasises prevention and empowerment in a linked way — i.e. prevention is most likely to happen if people are enabled to have increased agency and control in their own lives.

For the public health prioritisation process to succeed it was clear that significant engagement would need to take place. There was limited time and resources to approach this prioritisation process in a highly structured way (e.g. involving widespread survey-based data collection from the public as a whole); instead, diverse stakeholder opinions, based on their lived experience of what might work in the Scottish context, were identified as the basis for wider engagement. Stakeholders were identified by all the key Scottish public health decision-making bodies, including the Scottish Government, NHS (both national institutions such as NHS Health Scotland, and public health professionals working in local NHS Health Boards) as well as the Convention of Scottish Local Authorities (COSLA). Although a public online consultation on the long-list of potential priorities was launched in early 2018, lasting for a limited time (weeks), it was never clear precisely what sorts of self-selected respondents were represented in it, so that those data played a limited role in the EAG's deliberations. [In the Discussion below, we openly acknowledge that this was a major weakness of the entire prioritisation exercise.]

2.7. Stakeholder engagement for final prioritisation

Engagement events were held in large convention halls in three large cities across Scotland: Glasgow, Edinburgh and Aberdeen. These events brought together a wide array of stakeholders. With over 400 participants in total, the events presented an opportunity to inform delegates on the wider reform programme as well as focus in on the priorities. An overview of the Evaluation Framework and Evidenced-based Criteria was presented by members of the EAG, framed deliberately in non-technical language, to orient delegates for these workshops. Working in small “table-groups”, participants refined the criteria and proposed a long list of potential priorities, which were kept projected on the screen within each meeting hall.

Each table-group, through the efforts of a pre-identified facilitator and recorder, then produced a final ranked list of priorities by applying the refined criteria to their long-list. The highly participative format of these events resulted in a wide-ranging list of priorities and rationales for their selection.

2.8. Analysis

The individual short list of priorities from each of the delegate groups was entered into a spreadsheet to obtain an overall list of headline priorities chosen on a group-by-group basis. Where a group identified a ‘composite’ priority i.e. one that encompassed more than a single issue or challenge, it was broken down into more tractable priorities, making as explicit as possible the rationale for the choices made. Priorities from the participants' table-lists were then mapped or grouped to a smaller number of broad priority themes by participants, facilitated by attending members of the EAG.

The list of broader priorities was then ranked in three ways:

• Ten points per table-list: Each table of participants' list of potential priorities was allocated a maximum of 10 points which were then split between the lists of individual priorities for that table. On a table with 10 priorities, each would be allocated 1 point, or on a table with 4 priorities, each would be allocated 2.5 points. For a given priority, the total number of points allocated across all the tables was calculated and then placed in rank order of the points.

• One point per priority: In this method each individual priority on every participant's table-list was simply awarded a point. As before, the total number of points allocated to each potential priority was calculated to produce a rank order of the potential priorities.

• Weighted by order: In this method the priorities ranked more highly by tables were given more of the ten points per table than lower ranked priorities, at a ratio of 2:1 for highest -ranked: lowest-ranked, regardless of the total number of priorities. Ranking by this method was only possible for 30/40 tables participants across all the meetings, (75%), as the resultant ranking was explicitly rejected by some tables. Where a table had not been able, or refused, to rank priorities, the ten points were distributed equally. [It should be noted that a deep-seated reluctance to select public health priorities is a well-established tendency among public health professionals more widely, likely reflecting their collective experience that public health must be “ready for any sort of emergent public health problem” – a view justified within two years of the end of this prioritisation process, when the COVID-19 pandemic hit Scotland. Notably, specific health protection activities of the sort that rapidly came to dominate the daily work of many public health professionals after March 2020, in their efforts to control the pandemic, were not prioritised in this exercise. This is perhaps a cautionary note about the limitations of prioritisation exercises that specify specific public health problems rather than generic public health services' capacity.]

None of these three approaches was considered to be superior to the others; they are merely provided to allow assessment of the impact of each scoring approach on the overall rankings that resulted (Table 3).

Table 3.

Final ranked priorities and their underlying scores.

	1: 10 points per table	Rank	2: One point per priority	Rank	3: Weighted	Rank
Mental Health and wellbeing	378	1	310	2	426	1
Poverty and inequality	371	2	320	1	425	2
Early Years (including Adverse Childhood Experiences)	303	3	260	3	337	3
Diet and obesity	300	4	260	3	271	5
Housing	267	5	220	5	273	4
Physical activity (including active travel)	235	6	210	6	242	6
Alcohol	222	7	210	6	219	7
Built environment and place	208	8	190	8	212	8
Work and education	177	9	150	9	176	9
Improve Public Services	145	10	130	10	136	11
Power/Community empowerment/development	137	11	130	10	140	10
Social isolation	129	12	110	13	115	12
Tobacco/smoking	107	13	120	12	106	13
Climate Change	102	14	80	15	87	15
Drugs	97	15	100	14	89	14
Health protection	90	16	80	15	78	17
Transport	74	17	50	19	82	16
Older people/Healthy ageing	70	18	80	15	62	18
Environmental Health/Air pollution	55	19	60	18	46	20
Vulnerable Groups/Stigma/Exclusion	51	20	40	21	41	21
Green space	49	21	50	19	49	19
Remote and rural health	41	22	30	24	34	22
Screening	33	23	40	21	30	23
Vaccination and Immunisation	32	24	40	21	29	24
Unintentional injuries	28	25	20	26	22	28
Health Intelligence/Technology	27	26	30	24	25	25
Controlling and managing chronic conditions	26	27	20	26	23	27
Violence and abuse	23	28	20	26	24	26
Sexual health and relationships	17	29	20	26	19	29
Antibiotic Resistance	17	30	20	26	14	31

The point scores provide an indication of the level of separation between each rank, and the rankings provide the order. There are some natural breaks in the top ten priorities with two clearly dominant priorities (i.e. mental health and wellbeing; and poverty and inequality) followed by a fairly steady decrease in preference across the remaining priorities.

The rationales for selection were analysed and short lay-language summaries were written to accompany each of the top ten priorities chosen, to help achieve a common stakeholder understanding of each one.

2.9. Integration of inputs and finalisation of recommended priorities

A smaller gathering of the Expert Advisory Group (EAG), comprised of senior public health and local government professionals, was then convened to review the entire output and propose the final list of priorities.

In addition, the resultant short-listed priorities were scrutinised by elected representatives at a number of points. The Minister for Public Health and Sport reviewed drafts and rationales; elected local Councillors scrutinised reports through meetings of the Convention of Scottish Local Authorities; with the entire process overseen by the Public Health Reform Oversight and Programme Boards. That process was deliberately expedited to ensure that the priorities were formally accepted in time to influence the imminent reorganisation of Scotland's public health infrastructure.

2.10. Public health priorities for scotland

The final list of priorities, which the steering group felt strongly should number no more than six, in order to prevent dissipation of effort and miscommunication to the broader public, were phrased in terms of the aspiration that the priorities reflect “a Scotland where we …

• 1. …live in vibrant, healthy and safe places and communities.
• 2. …flourish in our early years.
• 3. …have good mental wellbeing.
• 4. …reduce the use of and harm from alcohol, tobacco and other drugs.
• 5. …have a sustainable, inclusive economy with equality of outcomes for all.
• 6. …eat well, have a healthy weight and are physically active.

The final publication set the national context for the issues selected was produced and published in May 2018 [16], and the official launch of the priorities occurred on June 14, 2018, only six months after the prioritisation process was initiated.

3. Discussion

3.1. Main finding of this study

Using an approach that is evidence-based, engagement-led and transparent, it is possible to rapidly (within four months from start to finish) and inexpensively develop a set of shared public health priorities with diverse stakeholders.

Due to the complex and contested nature of what constitutes public health and a lack of convergent, high-quality evidence on the precise cost-effectiveness of relevant intervention options for major public health priorities such as those listed above, it is virtually impossible to utilise purely rationalist, quantitative approaches to set public health priorities to the extent they have been carefully developed and promoted – for setting clinical or research priorities [15].

3.2. What is already known on this topic?

There is a substantial body of literature on prioritisation in a wide range of fields. Much of the published research in the field of healthcare priority setting has focused on healthcare technologies, prioritisation of interventions, or on priority areas for research. These decisions are dominated by health economic considerations including cost-utility and cost-effectiveness analyses. These are highly unlikely to be transparent to the public or non-health-sector stakeholders and require data not readily available or convergent across studies, for many public health interventions.

3.3. What this study adds

This paper is one of the first published accounts of public health priority identification in a modern setting using participatory methods. We have provided a set of principles, a typology of public health priorities, criteria for prioritisation, and a reflective account of public health priority-setting which can be replicated or adapted in other settings.

3.4. Limitations of this approach – some reflections

This article provides an outline of our approach, but it cannot serve as an evaluation. The Scottish 2015 Public Health Review recommended the creation of national public health priorities on the basis that they would focus concerted action across the whole system, so as the have the best chance of producing population health improvement. There is no evidence yet that having nationally agreed priorities has led to health gains – and indeed, the subsequent arrival of COVID-19 on the Scottish and global scenes would make such an evaluation methodologically fraught. Evaluating the longer-term impacts of creating these priorities is, however, a responsibility of the new Public Health Scotland, formally launched in 2020 [17].

A recognised limitation to our approach is the lack of wider public involvement. In the compressed timescale and very limited budget available for this priority-setting process, there was limited opportunity for such a broad participative approach, but we strongly recommend that much bolder efforts to engage the general public be trialled and evaluated by other jurisdictions, as a key element in future prioritisation processes of this kind. A particular challenge, as noted under Criteria #3.1 in Table 2, is that merely surveying the public (for example online, as was briefly attempted in this planning process) is not very productive. What is required is a more lengthy and interactive form of public engagement which starts with the provision of basic information on what public health is, as opposed to basic clinical services familiar to everyone. Doing this properly for a substantial sample of the general public was well outside the scope of the planning exercise described above, in terms of both time and resources. Indeed, a major public consultation conducted in 2015–6, identified almost exclusively clinically oriented service concerns, despite contacting over 360,000 individuals, nearly 10,000 of them in face-to-face events [18]^.

As well, we openly acknowledge that the sort of “populist” prioritisation approach described above will always tend to favour short-termism, in that challenges to the public's health and wellbeing which are more remote in time and “woollier” in their causal links to health – such as climate change – are most unlikely to be prioritised. Similarly, concerns of minority populations and special interest groups, no matter how worthy, are unlikely to be ranked highly – e.g. racial/ethnic disparities in health, which, at least in terms of visible minorities, constitute only a few percent of the entire Scottish population. On the other hand, if democratically broad participation is to be achieved, was explicitly required of the process described above, it is difficult to reconcile all these considerations with such an approach.

We have already mentioned that there is a strong tension among public health professionals regarding the wisdom of using such prioritisation processes, no matter how well done, to actually allocate more (or fewer) resources to existing organisational elements within the national infrastructure, such as health protection – particularly in the wake of a largely unforeseen pandemic which has ended up dominating the working lives of most public health personnel internationally for the last two years. Perhaps that is simply too high a bar for any prioritisation process to pass, in that foresight of such major new disease outbreaks could not be realistically expected in early 2018 when this exercise was conducted. On the other hand, however, the subsequent events surely argue for relatively frequent re-prioritisation of public health activities, especially if new priorities over time are to guide actual resource allocation.

Finally, it is worth reflecting on the potential biases of the EAG itself, given than virtually all its members (apart from the representative from the Scottish Council of Local Authorities (COSLA) had substantial expertise and experience as public health professionals and/or academics. Two factors mitigated the risk of such bias, although one cannot discount its presence in our deliberations entirely. First, several of the Expert Advisory Group members were employed in institutions completely independent of the Scottish Government, the NHS and official public health agencies (e.g. universities, the Glasgow Centre for Population Health, and COSLA). The other EAG members, who were more closely tied to official public health agencies and government, may well have felt some pressure by special interest groups to ensure that specific programmatic activities of substantial historical importance – e.g. vaccination and maternal-child health -- were included in the initial long-list of potential priorities. On the other hand, we note that the long-list was carefully designed to restrict all these potential priorities to the column “Systems and services,” leaving the other two columns (Table 1) entirely free of traditional public health administrative labels.

In the end, it is probably still premature to judge the impact of the above priorities on Scotland's public health services and their functioning, let alone on the major public health problems identified in them. The subsequent “commandeering” of the vast majority of public health professionals in virtually every global jurisdiction, by the COVID-19 pandemic, has meant that serious work on most other public health priorities were essentially “put on hold” until well into 2022. However, as we now (hopefully) emerge from that challenging era, it is noteworthy that the public health priorities developed in the process described here are still very much in place, enjoying broad support – both within the new agency PHS and also among the diverse stakeholders represented in those priorities' generation, nearly a half-decade ago.

Funding

No funding was received by any of the authors for their work on this paper, apart from the salaries associated with their usual employment.

Ethics

Because no identifiable human subjects or their data were involved in any research for the project described in this paper, and the work was commissioned by the Scottish Government as an unfunded collaborative planning project, rather than research, it was exempt from the usual Ethical Review processes.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.