Developing the good governance toolkit: a research-derived actionable tool

Abstract

Objectives

To share learning from the development of a Research-Derived Actionable Tool (RDAT) focused on improving governance of commercial interactions to benefit public health.

Study design

Mixed-methods combining synthesis with expert input.

Methods

Four principles were used for decision-making on scope and judging conflicting evidence. We combined synthesis of published evidence and grey literature with expert input from different perspectives (research, practice, non-governmental organisations).

Results

The methods used enabled decision-making to produce an RDAT, The Good Governance Toolkit, which was considered by the expert panel to be feasible and acceptable.

Conclusions

It was possible to develop a tool in advance of practice to support action in an emerging field of public health. Evaluation is underway.

What this study adds

• •The Good Governance Toolkit, published by ADPH, aims to improve governance of commercial interactions in UK local authorities to maximise benefits and minimise harms to public health
• •Describes methods used to translate evidence into a Research-Derived Actionable Tool
• •Explains decision-making principles used to develop the tool

Implications for policy and practice

• •UK local authorities and others can use the Good Governance Toolkit to develop policy, for learning and education, and to support ad-hoc decision-making
• •Appropriately addressing commercial determinants of health, including through Good Governance, offers an opportunity to improve public health and reduce inequalities
• •Documenting methods of tool development offers lessons for others to build on and opportunities to improve for future similar developments
• •Evaluation of the process and impact of the tool will be important to improve it through use.

1. Introduction

Addressing commercially-driven health-harms offers a substantial opportunity to improve health: analysis from the Lancet series on the Commercial Determinants of Health (CDoH) suggests that health-harming industries contribute to at least a third of deaths globally [1]. Another paper in the series indicates ways to interrupt the different mechanisms by which harm is perpetuated, including by preventing undue influence on policy making processes [2].

In the UK, local authorities are natural agents of change, shaping determinants of health through their varied powers, statutory duties, assets and resources. To build on the opportunities available in these settings, we developed a Research-Derived Actionable Tool (RDAT) [3] that aimed to support UK local authorities to maximise benefits and minimise harms to public health by improving governance of commercial interactions. This toolkit fills a gap by distilling academic knowledge into clear, actionable and pragmatic guidance that can be aligned to local values [4].

The objective of this paper is to share learning from the development of this toolkit.

2. Methods

We used four principles to guide the development of the toolkit:

• 1)Concise sufficiency: only include material that directly helps local authority colleagues tackle local issues.
• 2)Getting started over perfection: prioritise a timely, actional output that can be iterated and improved through practice and evaluative research.
• 3)Guidance rather than direction: aim to help local authorities, which are independent, varied and democratically accountable, to develop the right policy for their organisation and the population they serve.
• 4)Evidence-informed: draw from existing evidence on harms and how to address them in different contexts.

The principles informed both the methods (Table 1) and the decision-making process for refining scope and resolving any conflicting evidence (including stakeholder input) into a final resource.

Table 1.

Summarised methods.

Method	Document search and analysis	Expert input (workshop)	Expert input (other)	Drafting and revisions	Publication and dissemination
Analysis and synthesis of data was undertaken throughout using reflective writing and discussion as methods.
Purpose	•Develop and refine outline structure •Boundaries of content	•Collate range of views on specific aspects of content •Enable open discussion •Aiming to explore breadth, divergence and convergence of views, not to reach consensus	•Detailed input on specific areas •Opportunities for “off the record” feedback or insight	•Develop and refine content •Detailed feedback from stakeholders •Quality assurance from final key peer reviewers to guard against major errors or harm	•Awareness of the toolkit •Encouraging use •Professional design to increase ease of use and confidence from formal design •Publication by ADPH added confidence
Description	Purposive searching based on existing knowledge of research team, recommendations from stakeholders, internet and key website searches and snowballing techniques. Searches for •examples of existing policies, •toolkits with similar audiences or content, •research about governance and conflicts of interest.	90 min online workshop on three key topics: •What do organisations need in place to introduce policy •Potential challenges for implementation •How to help organisations determine policy scope	Individual stakeholders asked to contribute on specific issues based on gaps in documentary and workshop evidence. Discussions took place by video calls or emails as preferred by stakeholder.	Draft 1: Outline structure of the toolkit with headings for each proposed section along with summaries of expected content, ideas about format and proposed approach to drafting content. Draft 2: Key content in place. Some sections complete to allow feedback on style and format. Gaps where further input needed highlighted. Draft 3: Full draft circulated for “red line” comments from four key peer reviewers.	Design paid for by SPECTRUM & Stirling Publication by ADPH
Timing	Searches Sept 22 Recommendations and snowballing Sept-Dec 22 Analysis Sept-Dec 22	Nov 2022	Sept 22-Jan 23	Draft 1: Dec 22 Draft 2: Aug 23 Draft 3: Oct 23 Toolkit finalised Jan 24	Launch Apr 24
Simple descriptive statistics		16 stakeholders (4 Local Authority, 7 Non-governmental/regional/national policy organisations, 5 academic).	12 stakeholders with relevant expertise in developing similar toolkits or policies, academic expertise or local practice expertise.		128 attended an online launch event, 160 registered and received follow up information.

Editorial decision-making rested with the co-authors who had both worked extensively in local authorities and had also been working on CDoH in academic contexts shortly prior to and during the development of the toolkit. We weighted different expertise based on its relevance to the issue [4]:

• •practitioners’ expertise for issues of accessibility, ease of use, and pragmatic concerns
• •academics’ expertise for research evidence
• •NGO and national/regional colleagues’ expertise on coherence or variation across topics or cross-contextual factors.

Document search and analysis was designed to prioritise materials applicable to local authority settings (Principle 1) and to use stakeholder knowledge of the field to safety-net our non-exhaustive approach (Principle 2). We considered the framing, style and structure of existing materials as well as the content (Principle 1,4) in order to model our resource on others that stakeholders reported to be useful and acceptable in local authority settings.

The workshop drew from a range of facilitation methods (see for instance Liberating Structures [5]) to seek expert input on a clearly defined set of questions that could not be addressed by the existing published evidence base (Principle 1, 2). By focusing on open discussion rather than consensus, we were able to draw out a range of sometimes conflicting expert views. When resolving the workshop findings, we used both our guiding principles (Principle 1, 3, 4) and consideration of domains of expertise.

The methods described in Table 1 were not implemented in a linear way. For example, individual expert input was invaluable throughout. It was initially sought in the planning stages, then it was drawn on again during the analysis and synthesis of data to inform editorial decision-making where gaps in the evidence base meant judgement calls were needed and to gather views on the balance of competing risks and how to manage these. Finally, it was used towards the end for feedback on content and format.

Drafting and revision provided opportunities to refine, test and check our approach in an iterative manner. When drafting, we were mindful of our intended local authority audience, who experience strong time- and resource-pressures (Principle 1, 2). We emphasised readability and usability. For instance, separating the guidance from the supporting evidence allowed readers to understand the key points as quickly as possible, whilst providing them with a clear evidence-base behind each recommendation (Principle 4). The toolkit’s modular structure was intended to allow readers to pick and choose which parts of the toolkit to use depending on their context and needs (Principles 1, 2, 3).

3. Results

We developed a modular set of documents: the Good Governance Toolkit [6], which aims to support UK local authorities to ‘improve governance of commercial interactions, relationships and influence … to maximise benefits and minimise risk for population health.’ This toolkit has been published by the Association of Directors of Public Health and includes seven sections, a foreword and an accompanying set of flow-charts to inform policy and decision-making. The sections cover how to use the toolkit, the case for using good governance to protect health, issues to consider and evidence to support managing private-sector engagement in governance policy development, benefits and key issues to be aware of, principles and content considerations for policy and process, FAQs, and a glossary.

An evaluation of the process and impact of any implementation is underway and being led by the Local Health & Global Profits Research consortium [7].

The methods we used enabled us to make decisions about scope and resolve conflicts. One example that illustrates how these methods supported decision-making relates to differing stakeholder views about scope. Some recommended starting with a set of specific health-harming industries, where evidence of harm related to conflicting interests is strongest. However, academic evidence highlighted the risks that ‘tobacco exceptionalism’ may bring to progress in other policy areas [8]. The workshop format enabled us to explore and understand the different perspectives and the reasoning underpinning them. Through analysis using reflective discussions, we decided to prioritise a broad approach rather than focusing on specific industries, whilst working to mitigate concerns raised by some stakeholders. Our reasoning was partly based on prioritising research evidence for content decisions (Principle 4 and expertise weighting); partly about adding value to existing approaches, which had tended to focus on single industries or groups of them; and partly about prioritising democratic accountability and providing local authorities with the tools to develop approaches to suit their context and needs (Principle 3).

Our iterative approach enabled us to check proposed mitigations to address concerns with expert stakeholders. For example, to mitigate concerns that a broad approach may feel overwhelming and lead to less progress, we used design (a modular structure) and dissemination plans (for example explicitly stating the intention for people to use the toolkit in different ways, suggesting some starting points that could include choosing a limited number of industries or policy processes). The effectiveness of these mitigations can be pursued as a line of enquiry through evaluation.

4. Discussion

We theorised that this toolkit could contribute to improving population health through changing ways of thinking about governance and conflicting interests, supporting decision-making or introducing new policy. Policy change depends on local factors including political will and local authorities vary in readiness for action on CDoH. Therefore, whilst the toolkit’s intended use-case is to support policy development, we have also recommended its use for learning material, developing a case for change, and ad-hoc decision-making. In some cases, wider use of this material may help open the policy window to enable the full use-case.

4.1. Strengths and limitations

Strengths of the toolkit are that it clearly describes the target audience and setting, is adaptable to context, prioritises action, provides a suitable range of supporting evidence, takes account of existing structures and systems, and is considered by our expert panel to be practically feasible and support implementation. It therefore meets many criteria considered highly relevant for planning system-level health promotion [9] and enabling factors considered important in RDATs [3].

The key limitation of this toolkit is that, at time of publication, it had not been fully implemented. This means that its feasibility had not been tested in the real world, and experiences from direct application or testimonies could not be incorporated. The planned evaluation will enable lessons from implementation (including resource implications) to be built into future iterations of the toolkit.

4.2. Conclusions

It was possible to develop an RDAT in advance of practice to support action in an emerging field of public health. This report presents a pragmatic, real-world approach to translating academic evidence into local practice. Toolkits for public health practice are subject to a different set of standards [3] and priorities to academic work, and so the methods for producing them must also differ [10]. By publishing our methods, we aim to encourage timely and appropriate evidence-informed action across emerging fields of public health where more rigorous approaches may lag behind. We also hope to contribute to thinking and debate about methods and standards for RDATs.

Ethical statement

Ethical approval was not sought for this project because it did not present primary data but rather aimed to translate existing evidence for practice.

Funding

Anna Brook is funded by UK Research and Innovation funding for “Local Health and Global Profits” (Grant no MR/Y030753/1) which is part of Population Health Improvement UK (PHI UK), a national research network which works to transform health and reduce inequalities through change at the population level.

Katherine Körner was funded by Health Education England as a Public Health Registrar.

The Good Governance Toolkit was published by the Association of Directors of Public Health and the design of the report was funded by the University of Stirling and the SPECTRUM consortium which is funded by the UK Prevention Research Partnership (UKPRP), a consortium of UK funders [UKRI Research Councils: Medical Research Council (MRC), Engineering and Physical Sciences Research Council (EPSRC), Economic and Social Research Council (ESRC) and Natural Environment Research Council (NERC); Charities: British Heart Foundation, Cancer Research UK, Wellcome and The Health Foundation; Government: Scottish Government Chief Scientist Office, Health and Care Research Wales, National Institute of Health Research (NIHR) and Public Health Agency (NI)].

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.